The HSE is unable to say how many cases of a potentially fatal head injury associated with instrument deliveries have been reported to the National Incident Management System. The agency was asked on March 19 where one could find records of SubGaleal Haemorrhage cases being logged with NIMS, which is the HSE’s incident management tool developed to improve patient and service user safety.
After 52 days, the HSE stated “there isn’t a database that specifically captures SubGaleal Haemorrhage”. Despite it being pointed out to the HSE that there is a dedicated option specific to SGH on a key NIMS data form (see page 2 of the form at the end of this post), the HSE has consistently refused to provide the data requested.
The reason for the request in the first place was a follow on to a story published in the Irish Examiner on March 19, which featured a call for a review of existing nationwide data around adverse events in instrument-assisted births. The call from Safer Births Ireland itself followed a review of nine such births in University Hospital Galway which included incidents where babies suffered fractured skulls during birth.
This was after a suction cup was attached to their heads and pulled onto help in what is called a ventouse or vacuum-assisted delivery. The practice is still used in around 9% of births.
It has, however, been associated with significant trauma for those involved, and can lead to SGH. The review in UHG was initiated after a higher than normal incidence of SGH cases was noted in 2022.
Each case was reported and logged with the HSE’s National Incident Management System (NIMS) body which manages and oversees serious hospital incidents.
The resulting review reports were sent to each family, and a number of recommendations were made.
However, the Irish Examiner was made aware there were - at the time - at least 11 other cases where babies suffered trauma around the country.
The issues in Galway emerged after an earlier case, in May 2023, involving a boy who ended up with brain damage after a skull haemorrhage went undiagnosed after his delivery at The Coombe Hospital.
That same story reported that the case was settled with a €6m interim payout.
The High Court heard Jack Clavin - six at the time of the hearing - had to have an emergency craniotomy nine days after he was born.
An emergency CT scan subsequently found he had suffered a subgaleal haemorrhage and a stroke.
The Coombe Hospital offered his parents, Co Meath’s Nicolina and Dermot Clavin, their “sincere and unreserved apologies for failings in care that caused injury to Jack” and they said they “sincerely regret these failings led to lifelong consequences”.
The HSE still - as of October 15, 2024 - refuses to divulge information that could give any insight into how many SGH cases have been referred to NIMS.
After 211 days of this reporter trying to get the information, a HSE press officer stated on October 15, 2024: “We do not have the resources to provide responses to these queries.”
About NIMS
NIMS - according to Health Information Quality Authority (HIQA) - is “the principal source of national data on incident activity for the Irish health service designated as the primary system for end to end risk management of all incidents both by the Department of Health and the HSE.”
The health watchdog also describes a wide number of the purposes of NIMS. These include: capture of Serious Reportable Events (SREs) including dangerous occurrences and complaints, management of incident reviews, recording of review conclusions, recording of review recommendations, tracking recommendations to closure and reporting and analysis of patient safety incident data as well as reporting and analyzing review conclusions and contributory factors. Its purposes also include facilitating the analysis of safety performance to inform risk initiatives.
While, according to Hiqa, the HSE owns the NIMS healthcare data with respect to patient safety/service user incidents, the State Claims Agency (SCA) is the joint controller of incident data and ‘owner’ of data with respect to patient safety related claims.
Also according to Hiqa, the HSE in conjunction with the SCA jointly manage NIMS. Finally, its stated purpose is “to maintain and provide the national database of patient safety incident data that meets the needs of data users in the health and social care sector (including quality and patient safety clinical teams, management, policy makers, risk/health and safety managers, facilities staff, and researchers) whilst also supporting effective claims and risk management by the HSE and the SCA. In terms of patient safety data, this is probably the single biggest centralized system holding it.
The HSE was asked the following set of questions about NIMS data:
How many serious Reportable Event incidents were there in 2023 involving Category 1 outcomes of neonatal deaths of service users in acute hospitals?
Of such deaths, how many involved which of the following type of hazard - a) Diagnosis Delayed; b) Diagnosis Misdiagnosis/Incorrect Diagnosis and c) Missed Diagnosis?
Of such deaths, how many involved which of the following delivery types - a) Instrumental Delivery (Forceps); b) Instrumental Delivery (Vacuum/ Ventuse/Kiwi) and c) Instrumental Delivery (Multiple Instruments)?
Of such deaths, how many involved a) Placental Abruption PPH; b) Uterine Rupture; c) Incomplete/inadequate Communication and d) Incomplete/inadequate Consent.
Despite six reminder emails sent over 124 days between August and October, 16, 2024 after the questions were asked on June 16, 2024, the questions remain unanswered.
