The HSE has launched an investigation into baby deaths data it already has but isn’t looking into another set of data it should have - the conclusions of 488 Serious Reportable Events investigations into baby deaths and injuries over the past four years.
According to the HSE, the object of a Confidential Inquiry into data on baby deaths is a “separate process” to investigations into a Serious Reportable Event investigation report into baby deaths and injuries.
While it already has one set of data - perinatal mortality data linked to actual baby deaths - it doesn’t have the conclusions of 488 Serious Reportable Events investigations in the past four years because it doesn’t collate the information centrally.
The objective of the HSE’s Confidential Inquiry is to “extract learning” (see below).
Coincidentally, the objective of an investigation into a Serious Reportable Event is “learning from things that go wrong” which is - according to the HSE - “the bedrock of making systems safer”.
The Irish Examiner asked on August 7, 2024: “If there have been 488 Serious Reportable Events (related to baby deaths and injuries in maternity units) in the past four years where there is a mandatory requirement that they be reported to NIMS and that an investigation be launched within 48 hours and that an investigation be completed within four months - why is that not seen as a potentially rich source of information that merits a Confidential Inquiry in its own right?
“Why is the HSE starting something new with its Confidential Inquiry into the anonymized data on perinatal deaths held by National Perinatal Epidemiological Centre (NPEC), when in fact what it could have done is go to all the hospitals that reported SREs in the past four years and look into them?
“The work has already been done, or should have been done and rather than the HSE trying to figure out which of the perinatal deaths data NPEC has relates to anything it needs to know about in terms of adverse outcomes, or even worrying trends etc - surely it is actually this data it should be looking at, especially if the HSE is interested in getting this work done in a timely manner.”
The HSE responded: “Every reported incident is reviewed by the HSE (relevant hospitals) as required and set out in the Incident Management Framework.
“The National Incident Management System (NIMS) provides insight into the collective data but the confidential enquiry is an internationally recognised method of extracting learning, which is why it was recommended by NPEC.
“In a confidential enquiry, case notes are anonymized and then sent to an independent review panel. The review panel produce their findings in a standardized manner, which allows for trends to be identified and facilitates learning.
“This is complex, and cannot be achieved by “sending around a few emails,” as you suggest.
“Each case is independently reviewed by appropriately qualified experts.
“The process is robust, comprehensive and independent and amalgamating individual reports, with different format and approaches, from individual hospitals would not achieve the same objective.”
The Irish Examiner asked on August 8: “Given that - as the HSE says - "the confidential enquiry is an internationally recognized method of extracting learning", and that would appear to be the sole objective of the inquiry, what is the overall objective of HSE maternity hospital-initiated investigations into SREs independently reviewed by appropriately qualified experts and how are their objectives any different to the objective of the Confidential Inquiry?
HSE response:
“These are two separate processes. A review under a Serious Reportable Event (SRE) is designed around the family at hospital level, in line with the Incident Management Framework.
“Nationally we are working to collate incident reviews and ascertain learning.
“The HSE launched the platform Patient Safety Together in 2023 for the purpose of sharing learning across the HSE.
“The new annual review and report (confidential enquiry) facilitates system-wide learning, as recommended by National Perinatal Epidemiological Centre (NPEC).”