Institute of Obstetricians and Gynaecologists calls for Clinical Review Team recommendations to be fully implemented to improve patient safety at maternity hospitals

Additional doctors and midwives required to support on-going training and safe patient care

The Institute of Obstetricians and Gynaecologists is today, 22 June 2015, calling for the implementation of the ten recommendations put forward by the Clinical Review Team of six Consultant Obstetricians led by the Institute’s Chair, Dr Peter Boylan.

The team’s review of 28 case notes from maternity units in Portlaoise, University Maternity Hospital Limerick and the Midland Regional Hospital Mullingar was requested by the Health Service Executive following the broadcast of a Primetime programme on RTE in January 2014. Their review, which is published at www.hse.ie today, makes 10 recommendations that, if implemented, can help to support safe care for women and babies. A further 103 cases are being separately reviewed by a clinical care team convened by the HSE.

Today Dr Peter Boylan, expressed his sympathies to the families who have suffered and who consented to having their case notes reviewed. “I wish to acknowledge the grief of these parents and to sympathise with them,” he said.

“The Clinical Review Team has recommended that a representative from the HSE should meet every parent who is affected to discuss its conclusions and recommendations in their individual case. It is clear that the handling of adverse outcomes when they occurred appears to have been a major issue, particularly in smaller maternity units.

“We are always working to reduce the number of adverse outcomes and we must ensure that where they happen, that parents are treated with respect and compassion and in a timely fashion. Having more doctors and midwives to care for mothers and their babies will ensure greater patient safety, continuous training and give them more time to care for patient needs,” Dr Boylan said.

“It is worth stating that the number of serious maternal incidents in Irish hospitals compares favourably with other European countries, despite the number of sad cases that have been highlighted over the past year.

“The recent second report from the National Perinatal Epidemiology Centre Audit of Severe Maternal Morbidity in Ireland has shown the incidence of a serious maternal event in Irish hospitals is 4.75 per 1,000 maternities in 2013, compared to Scotland where the rate is 7.3 per 1,000,” Dr Boylan said.

This is at a time when there are fewer Consultant Obstetricians and Gynaecologists per head of population in Ireland, with recent figures recording around 5 Consultant Obstetricians and Gynaecologists per 100,000 women here compared to 27 per 100,000 in other OECD countries.

The Clinical Review Team wants to see a monthly formal system of audit of pregnancy outcomes involving all relevant doctors. This will allow a pattern of adverse outcomes to be identified in a timely fashion so that appropriate action can be taken.

Other recommendations include:

  • The adoption of a formal system of review of adverse outcomes that should be shared with patients in a timely fashion, ideally within two months.
  • Every effort should be made to gain consent for a post-mortem examination and examination of the placenta by a perinatal pathologist in the event of a perinatal death.
  • Each hospital should ensure the appointment of a number of midwives trained in ultrasonography to ensure that high quality obstetrical ultrasound is available on a routine basis during the working week and on an on-call basis at other times.
  • Hospitals should appoint bereavement counsellors to deal with perinatal deaths.
  • Midwifery staffing levels should be at an adequate and internationally accepted levels in all hospitals
  • All non-Consultant Hospital Doctors working in maternity units should be part of a recognised training scheme
  • Each hospital should ensure that Consultant Obstetrician staff levels are at an adequate, internationally accepted level
  • Each hospital should implement on-going mandatory training programmes for all clinical staff in respect of day-to-day care of pregnant women where they do not already exist.

The Institute is the representative body for Obstetricians and Gynaecologists in Ireland, encompassing consultants and trainee doctors. A key role of the Institute is to advocate for maternity services, and it sees patients as partners in this endeavour. The Institute is also committed to continuing to work closely with its midwifery colleagues in a partnership model of care in the best interests of our patients.

For further information contact

Kate Healy 


Communications Manager


Royal College of Physicians of Ireland

Direct Line 01 8639698 | Mobile 085 8722109 | Email katehealy@rcpi.ie