All but one of four maternity units randomly selected for a national audit of baby heart monitoring in 2022 needed to immediately take action to avoid harming women or their babies, according to the HSE. Dublin's National Maternity Hospital received a “satisfactory” rating in the audit to check compliance with a National Clinical Guideline for Fetal Heart Rate Monitoring before birth in maternity units.

The audit included checking to see if the appropriate governance structures were in place for Fetal Heart Rate Monitoring (FHRM) and if there was full compliance with key recommendations regarding application, interpretation and documentation of FHRM as outlined in the National Clinical Guideline (NCG).

Four maternity units were randomly selected for audit from the 19 Maternity Units across the country. As well as Holles Street, they were Wexford General Hospital, Sligo University Hospital, and Midland Regional Hospital Portlaoise.

The HSE’s Internal Audit Division’s Healthcare Audit Unit concluded Wexford, Sligo and Portlaoise maternity units needed to take immediate action after they were subjected to site visits towards the end of 2022.

In records released under the Freedom of Information Act, the three hospitals were told they needed to take immediate action on a string of high priority recommendations. Most of these were because there were - on six occasions across the three hospitals - potential risks of “adverse outcomes” for mothers or their babies if the recommendations were not acted on “with immediate effect”.

Auditors repeatedly found the HSE’s NCG for FHRM had not been fully implemented. They found that outdated guidelines and information were being relied on instead.

In its summary report on the NCG compliance audit, the HSE stated findings indicated the level of assurance about adequacy and effectiveness of governance, risk management and internal control system for compliance with the NCG was “limited”.

Such a level is given where it is deemed there are “weaknesses” in governance, risk management and controls which “create significant risk the system will fail to meet its objectives”.  It also means “action is required” to improve adequacy and effectiveness of the system.

Auditors also stated: “The audit was to establish compliance with the NCG regarding FHRM. However, of the sites selected, three did not use the NCG, while one (Holles Street) did.

“There was no documentary evidence that women were informed about FHRM or offered the information leaflet associated with the NCG during the antenatal period. There was no record of affording women an opportunity to discuss this aspect of care including documentation of their individual preferences.”

The audit into Portlaoise maternity services had a number of key findings - one was that the hospital's maternity services "had not adopted the NCG to underpin fetal heart rate monitoring practices”. 

It also noted "not all midwifery and medical staff involved in the care of women in labour were up to date with fetal heart rate monitoring practices".

One of the risk implications noted in the audit report stated "there is a risk of failure to provide standardised, up to date, research based FHRM care based on the NCG may result in adverse outcomes for women and their babies".

Another noted there was "the risk of adverse outcomes for women and their babies if midwifery and medical staff involved in the care of the women during labour do not maintain up to date FHRM training every two years".

The HSE has not carried out any internal audits into CTG compliance since.

Hiqa was asked if it was aware the above audit into CTG NCG compliance had taken place and what the key findings were? It was also asked if Hiqa was regularly made aware of reports on internal audits the HSE carries out into hospital maternity services where there are key negative findings which may result in adverse outcomes for women and their babies?

In response, Hiqa stated: “Following a request from the Minister for Health in 2014, HIQA conducted an investigation into the governance and assurance arrangements that the Health Service Executive (HSE) had in place to ensure the safety, quality and standards of services provided to patients in the Midland Regional Hospital, Portlaoise. 

This investigation report was published on May 08, 2015. Among many things, it reported that the Investigation Team was “advised by some women that the volume of the alarms on their cardiotocograph (CTG) machine (a machine used to record baby’s heart rate while the baby is still in the womb) were turned down or silenced. 

“Two of these women told the Investigation Team that some staff had shown them how to silence the alarm. They also said that explanations as to why the alarm needed to be reduced or silenced were not given, or indeed what the alarm going off indicated.”

The report also noted, as far as CTG is concerned, that “most parents who met with the Authority during this investigation explicitly expressed the opinion that some staff who were involved in their care were uncaring and did not listen to what they were saying”.

They also told Hiqa: “This was a common theme running through the meetings with those met with by the Authority with parents saying they felt they were being talked about, were being ignored, and that they felt invisible.”

A number of local investigation reports since 2011 have, the report noted, recommended that all midwifery and obstetric staff at Portlaoise Hospital receive cardiotocography (CTG) training. 

“Given poor CTG interpretation had been identified as a significant deficit and risk in the hospital, the Investigation Team reviewed the arrangements in place to ensure that midwifery and obstetric staff were competent in the recording and interpretation of CTGs,” the report noted. 

“At the time of the investigation, data submitted to the Investigation Team showed only 72.2% of midwives had attended CTG practical training workshops, while figures were not supplied for medical staff attendance. This issue was again explored at the follow-up meeting with members of the Interim Management Team in October 2014. 

“At that time, the hospital was unable to confirm the exact number of midwifery and medical staff that had fully completed the K2 training module as required in its hospital policy.

Hiqa noted that “this is of concern and should be addressed as a matter of urgency”.  It added: “The Investigation Team recommends all midwives and clinicians involved in caring for women in labour must be competent in the monitoring and interpretation of CTG tracing. 

“Such competence can only be assured with the provision of comprehensive training supported by regular updates. Midwives and clinicians who have not completed the requisite training or the necessary updates should not undertake CTG monitoring or interpretation. 

“Senior midwifery managers and obstetric lead clinicians must maintain up-to-date records of staff training.”

Hiqa also referenced the fact that on December 5, 2016, it published a review to evaluate the progress achieved at Portlaoise Hospital in implementing the recommendations from its investigation report. 

By way of background, that report noted the HIQA Portlaoise Investigation Team reviewed the arrangements in place to “ensure that midwifery and obstetric staff were competent in the recording and interpretation of cardiotocography (CTGs)”. 

This, the report noted, was prompted by the findings of a number of local reviews since 2011, which had recommended that all midwifery and obstetric staff receive fetal monitoring cardiotocography training as poor CTG interpretation had been identified as a significant patient safety risk.

In a section entitled “What has changed since the HIQA Portlaoise Investigation?”, the report noted that the HIQA Review Team “was informed the current system in place to ensure that midwifery and obstetric staff were competent in the recording and interpretation of fetal monitoring involved two methods of CTG training”. 

It said the HIQA Review Team was provided with the fetal monitoring evidence-of-training report that was issued to the maternity unit in April 2016. 

This was, Hiqa said, “a comprehensive report outlining how many hours midwives and obstetric staff had participated in the online training programme in the previous 12 months and what modules were completed in the time frame”. 

It concluded: “Training records for midwives were also provided, and indicated 98% of midwives currently employed in clinical practice in the maternity services were up to date in this aspect of their CTG training. 

“Overall, it was evident to the HIQA Review Team that fetal monitoring training was well attended by obstetricians, NCHDs and Midwives.”

Lastly, the HSE said in its December 2023 that a third strand in its response was the fact that in early 2020, HIQA published an overview report of its monitoring programme against the National Standards for Safer Better Maternity Services in Ireland’s 19 maternity units and hospitals, with a focus on obstetric emergencies.

Published in 12 February 2020, the Maternity Overview Report noted that “a number of important areas of non-compliance with the national standards need to be addressed at hospital group level and nationally by the HSE”. 

By way of example, it stated “HIQA has identified shortfalls nationally”. These included shortfalls in “the formation of maternity networks at hospital group level”, shortfalls in the “formalisation of care pathways for women and newborns”. Hiqa also noted “substandard physical environment and infrastructure of units and hospitals, inadequate midwifery and medical staffing levels (and) low uptake and recording of attendance at multidisciplinary training in the area of obstetric emergencies”.

Hiqa also noted shortfalls in “cardiotocography (fetal heart rate monitoring) interpretation and neonatal resuscitation, and measures to share learning around both good practice and when things go wrong across maternity services”.

It noted: “A number of key investigations and reviews into maternity care since 2011 have recommended all midwifery and obstetric staff receive cardiotocography training appropriate to their scope of practice. They have also recommended that staff should be competent in the monitoring and interpretation of a cardiotocography tracing. Such competence can only be assured with the provision of comprehensive training supported by regular updates. 

“HIQA found that there was no standardised approach to the provision of training in relation to cardiotocography interpretation across the maternity services. HIQA found that the rate of uptake of cardiotocography interpretation training within the required two-year time frame ranged from 19% to 100%. 

“Where weekly cardiotocography updates or meetings were held, this provided an opportunity for shared learning among obstetric and midwifery staff — this is a welcome finding and should be replicated across all maternity services. Difficulties in releasing clinical staff to attend training because of staff shortages were reported as a key challenge by some maternity units and hospitals. 

“Hospital managers also reported difficulties in monitoring the uptake of training in the management of obstetric emergencies and cardiotocography interpretation whenever NCHDs moved between maternity services. Hospital managers must be assured that clinical staff have undertaken their mandatory training requirements at the required frequency. The monitoring and recording of all staff attendance at training is essential to provide this assurance to hospital managers.

“HIQA noted that RCSI Hospitals Group monitored and publicly reported on compliance with the uptake of cardiotocography interpretation training and neonatal resuscitation training for each maternity service in the hospital group every month. The uptake of this training within the required two-year time frame for the maternity units and hospital in this hospital group ranged between 90% and 100% and is an example of good practice in this area.”

Hiqa said in conclusion: “Overall, maternity services were found to be very reliant on front-line medical or midwifery staff working onerous rosters or overtime to maintain service levels. In the longer term, such arrangements raise significant questions around sustainability and service safety. HIQA found there was significant scope for improvement in many services around practices to ensure all staff were up to date with required training in dealing with obstetric emergencies, neonatal resuscitation and cardiotocography interpretation. This represented one of the more significant findings requiring short-term action by maternity units and hospitals and the HSE.”