Ireland's Maternity Staffing Levels are an Epic Safety Failure

 Ireland's Maternity Staffing Levels are an Epic Safety Failure

On Friday we saw yet another damning report into unsafe clinical practices and an underlying culture within the HSE which has contributed to deaths in Irish maternity hospitals. This was not the first report of its kind. In fact, it has only been a matter of months since the last. What was interesting in the report was that while there was recognition to the grave failures to provide safe clinical care, an underlying culture which lacked accountability and humanity, and serious concerns over communication and transparency.... the report failed to cite staff levels as a contributing factor.

This was a big surprise.

While AIMSI are delighted to see that communication failures and transparency are cited within the report from Portlaoise, it seems to be an over-sight that the reoccurring complications of an over-stretched and under-staffed system have not been taken into account.

 

Here's a few reasons why. 

 

Safer Childbirth Standards - RCOG and RCM - 2007

"Inadequate midwifery staff will lead to many women being left alone for long periods of time when they feel very vulnerable. Incidents like bleeding, drop in blood pressure or abnormality in the fetal heart rate may not be picked up in time to avoid morbidity."

Safer Childbirth standards (RCOG et al 2007
(Written evidence, RCOG)


"The minimum midwife-to-woman ratio is 1:28 for safe level of service to ensure the capacity to achieve one-to-one care in labour (BR+ evaluation  data).89,90 The midwifery total care ratios for services with more complex case mix must be determined locally after case mix (social and clinical determinants) and external workload assessment is done, this may mean a lower midwife to woman ratio up to 1:25. The recommended total care ratios indicate the maximum number of women that a midwife can provide antenatal, intrapartum, and postnatal care for within the service. "

Safer Childbirth standards (RCOG et al 2007)   
Irish midwife to woman ratios vary but we have heard consistent calls from Masters of the Rotunda, former Master of the Coombe, and others citing midwife to woman ratios in Ireland to be at desperately unsafe levels in Irish units. Numbers cited have varied from 1:47 in the Rotunda to 1:55 and 1:75 in Portlaoise.

In addition, the HSE has not chosen to establish any more midwifery-led units, in addition to the two pilot units in Drogheda and Cavan despite an extensive HSE-financed Randomised Controlled Trial of those units indicating (Mid-U study):

-better birth outcomes

-fewer interventions

-more cost effective births

For normal low-risk women

(SNM, TCD, MidU Report, 2009)

We know from the extensive 2011 National Perinatal Epidemiology Unit Birthplace Cohort Study in the UK that for low risk women, best, safest and most cost-effective results are obtained from midwifery-led units (Brocklehurst et al., 2011).

March 9, 2007 Tania McCabe and her son Zach died at Our Lady of Lourdes Hospital in Drogheda.

The Midwife to woman ratio at the time of her death was over 1:48

 
HSE Report: Tania McCabe:
 
"Maternity Services at Our Lady of Lourdes Hospital have been under increasing pressure, with a significant increase in activity. This has resulted in the Maternity, Paediatric and Anaesthetic services being significantly under-resourced to cope with the current demands. This had an impact on Tania’s care, with staff working long hours while carrying an excessive workload. Despite the good intentions of staff who were working in very difficult conditions, their practice and ultimately the care that they provided to Tania were compromised by their workload and the environment in which they were working."
 
High Priority Recommendation: Continual Assessment of staffing levels
 
"The Review Team recommends that the HSE in conjunction with the Clinical Networks’ advice would seek to urgently upgrade the medical and midwifery staffing commensurate with the recommendations from Safer Childbirth (2007)."
 
In 2008 Rosaleen Harlin wrote: "Significant investment in recruitment has resulted in all but 6 of these posts being filled. This brings the midwife to patient ratio to 1:48.There are currently 6 midwives vacancies in the Maternity Department in Our Lady of Lourdes Hospital, Drogheda and efforts are currently being employed to address this"
 

 

2008 KPMG Review of Dublin Maternity Services

 In 2008, the HSE-commissioned report, Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area, by KPMG, with each hospital THEN delivering over 8,000 births per annum, stated:

"Based on the current model of care, compared to standards set by BirthRate Plus, BAPM and the RCOG in the UK, the hospitals are understaffed, with an additional:

20 obstetricians,
221 midwives,
20 neonatal nurses
and 35 theatre staff required across the three hospitals"
 
The public service embargo along with the numbers of midwives who have retired from the system from 2010 onward, under the voluntary early retirement schemes, mean that on many shifts in our maternity hospitals, midwives are carrying double the caseloads they should be carrying. Staff sickness levels are high and staff are leaving.

 While it is true that the birth rate has dropped nationally by almost 3% between 2011 and 2012, that does not bring our maternity units anywhere near the numbers of births in 2007/8 when the KPMG report already stated that we suffered significant understaffing by best international standards.

  

Portlaoise Midwives

 In 2006, 32 midwives from Portlaoise wrote to the Minister for Health concerned with staffing levels directly citing fears that levels will result in the death of a mother or baby. The midwife to woman ratio in Portlaoise has been reported on twice with conflicting levels. One report of 1:55 and another of 1:75.


Neither are safe nor appropriate staff levels.

 

"Not enough people to look after you"An exploration of women's experiences of childbirth in the Republic of Ireland - 2010

Objective: women's experiences of childbirth have far reaching implications for their health and that of their babies. This paper describes an exploration of women's experiences of childbirth in the Republic of Ireland

Focus group interviews with women from units which were randomly selected.

Findings: three main themes were identified, ‘getting started’, ‘getting there’ and ‘consequences’. Women experienced labour in a variety of contexts and with differing aspirations. Midwives played a pivotal role in enabling or disempowering positive experiences. Control was an important element of childbirth experiences. Women often felt alone and unsupported. The busyness of the hospital units precluded women centred care both in early labour and in the period following the birth. Some women would not have another baby due to their childbirth experiences.

Key conclusions: the context within which women give birth in the Republic of Ireland is important to their birth experiences. Although positive experiences were reported many women felt anxious and isolated. Busy environments added to women's fears and participants appeared to accept the lack of support as inevitable. Midwives play a pivotal role in helping women achieve a positive birth experience.

 Midwives SHOUT BACK

At the start of February women and midwives started a SHOUTBACK campaign. To tell their examples of why care is unsafe in Ireland from a professional view and examples from women of unsafe care they have experienced. These are a few SHOUT BACK contributions from midwives and their experiences working in an over-crowded and understaffed maternity system with a fundamentally flawed system. These contributions are from units all over Ireland. Urban and Rural. All saying the same.

SHOUT BACK - YOUR SAY: Be 'With Woman'...a Midwife, its what I trained to do, this profession was a passion for many of us, and I see on a daily basis that constraints the system, the hierarchically environment, the lack of on the ground support has made us dispassionate and akin to robots. Everyday I hear stories of fellow midwives leaving the system, dispirited and unsupported they have reached ...burnout stage, no longer having the energy to fight the system, they go along with the diatribe, suppressing their natural instinct, afraid that if seen to be different as they will be blackballed, there is no joy going to work and feeling alienated, or the odd one out. Yet I know they do try everyday to try and make birth better for the women in their care, no matter how bad the day, that passion and the love of midwifery is still there, engrained in their core, we need as women and Midwives to work together, lets not accept this anymore, lets make changes, NOW, SHOUT BACK!

 

SHOUT BACK - YOUR SAY: As a midwife I can safely say the only reason more people aren't dying is because birth is normal for the most part. There are near misses every day, dreadful post natal care, cattle market prenatal care. Lack of evidence based care is rampant. Midwives are cracking under this broken system. I, myself have taken many sick days because I just can't cope. As a I frequently had 12 women and babies to care for. This level of stress can not continue. Midwives are flocking to other countries. Better countries to work and give birth in

 

SHOUT BACK - YOUR SAY: I am currently working as a midwife in the Irish maternity system. It seems redundant to say that I work in a very busy and understaffed hospital, however I feel that perhaps the government and a certain minister may need a little bit of reminding. When I began my training as a midwife I knew it would be hard work; I was never afraid of that. However, in the last few years I... feel that my role has shifted from advocate, educator and supporter of women and their families as they traverse the amazing road of parenthood to somewhat of a firefighter. It is a constant struggle just to provide the bare minimum of safe care (and even then it is not always possible).

It is unsatisfactory to say that Ireland is one of the safest places to have your baby. Of course safety is paramount but merely sending a family home alive and "safe" physically is not the only benchmark to which the maternity system should be held accountable.I work with some phenomenal people who try their best every single day to provide as much care to women and their families as they can but it's just not enough. The pressure on our maternity system caused by lack of staff and adequate resources to cater to the number of high and low risk women is having a detrimental effect on the experiences of the clients and the health and wellbeing of the staff.

 I love my job, but it breaks my heart to come home after a long and exhausting shift to feel that I just didn't get a chance to truly support anyone, to employ the skills I have worked hard to obtain. It's a terrible thing to know what you could do if you had just a bit more support, just a bit more time.... you could make all the difference in the world to someone. And as selfish as it sounds, it could make all the difference to me, to all of us working here. No midwife that I know pursued this career to feel like an unwilling abuser, we do it because we know how important this moment is in peoples lives, and we want to help!

Job satisfaction is a wonderful thing and drives us to continue to support and care with everything we have. We glean what we can from a spare ten minutes to give an extra helping hand to someone who is breastfeeding, rocking with and rubbing the back of a woman in labour or having a few precious moments to genuinely listen to a woman about her concerns or worries and give reassurances or education. So often however, Its just not feasible and those moments are considered a luxury for us and the women. I am truly sorry to all the women I have cared for who may have left feeling upset, scared or traumatised and no one had a moment to sit and talk to them. It weighs on me all the time.

So many of us are close to breaking point, so close to leaving the job we love because it's turning out to be unsustainable to continue with those levels of pressure and stress on a daily basis without turning into an apathetic or unhappy person. I sincerely doubt that any woman would want to be cared for by someone who is unhappy and exhausted physically and emotionally.

I wish I had the courage to post this with my name on it, but I am afraid. I am afraid that the foxhole mentality of the maternity system will come crashing down on me; that I will be accused of putting words in other peoples mouths even though I hear these sentiments every day. Or worse, that I will be seen as someone who just can't handle it. I can handle it. I just don't think it's enough to be able to merely 'handle' ones job, especially when that job is so importance and carries such gravitas and may have implications for the rest of a womans life.

I suppose it boils down to the fact that although I'm doing the best I can with what I have, I want the opportunity to be the best that I possibly could be for the families I care for. If we could have that opportunity it would certainly make this an excellent place to have a baby.... not merely an acceptable place.

Its not enough to make recommendations.

 

Report after report. Recommendation after recommendation. And no action.
 

  Recommendations and guidelines in the current system go unanswered with no obligation to implement them locally. AIMSI are aware of maternity units which are still failing to implement recommendations (Amnisure) from the Tania McCabe report.

Why have these units not been held accountable?
Why does Ireland have an extensive library of National Clinical Guidelines which have not been implemented into local policy or practice?

The HSE needs to be fully audited and held accountability for its own compliance in creating a culture in which these scandals have been allowed to flourish.

There is a serious need for investment in evidence based care in Ireland. Obstetric led hospital based care must be fully equipped - not only with up to date equipment but also the appropriate safe staffing levels to prevent adverse outcomes for women who chose this care setting. In addition, investment in care options must be available in all units - including midwife led units, birth centres, and homebirth services.


Continuous safety failures clearly illustrate that the current care model needs an urgent overhaul and that health care providers are working in environments without clinical support - just getting by. Women and babies deserve one-to-one care based on the highest possible quality and evidence.
 

Related Reading:

Baby deaths 'not linked' to hospital's staff levels: http://www.independent.ie/lifestyle/health/baby-deaths-not-linked-to-hospitals-staff-levels-30055895.html

Safer Childbirth 2007: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/WPRSaferChildbirthReport2007.pdf

‘Far off’ level of care needed http://www.leinsterexpress.ie/news/your-community/far-off-level-of-care-needed-1-5899190

Portlaoise midwives wrote to Cowen and Harney over ‘fears that a mother or baby would die’ http://www.thejournal.ie/midwives-wrote-to-ministers-in-2006-expressing-fears-that-babies-would-die-1291780-Jan2014/

‘Not enough people to look after you’: An exploration of women's experiences of childbirth in the Republic of Ireland http://www.midwiferyjournal.com/article/S0266-6138(10)00186-5/abstract

Why has the Labour Ward gone to the Dark Side?

AIMSI welcomes this guest blog post from Dan Oakes, RM and Founder of Neighbourhood Midwives

Following the recent revelations about Irish maternity care in the news and social media, I wondered why there are so many different approaches to providing care to a mother in labour. The stories range from having an empowering midwife to a controlling obstetrician, a cruel midwife to a lifesaving obstetrician. Can it be that hard for all caregivers to provide consistent, respectful care? Or is something else at play here?

I am an avid video game enthusiast. I particularly like strategy/city building games. In many of the games I play, the player must choose to rule the subjects in their kingdom either with an iron fist or gentle care. Usually the cost of being a good ruler is higher in terms of time and money, but subjects are far more productive than the kingdom run by an evil player.

These observations are not exclusive to the fictitious video game world. They come right out of what we know of human history and science. Let's look at the situation through the lens of the Stanford Prison Experiment. Zimbardo (2008) writes in The Lucifer Effect: Understanding How Good People Turn Evil that it is not the bad apple that ruins the barrel, rather a bad barrel contaminating the apples. Does this theory mean it is the system that turns practitioners into monsters? Suffice it to say, we can all relate that it takes more time and effort to be kind to our fellow human beings; in fact, it is much easier to be flippant, uncaring and brusque, especially when we are under tremendous pressure.

Are the people helping women in labour in Ireland under tremendous pressure? In the recent prime time report on Portlaoise, the HSE reported that the midwives there are working at a ratio of 1:75. Considering the maximum ratio should be 1:28, I would hazard that not only are the staff under extreme pressure, but also actively encouraged to do whatever it takes to get mother and baby out of the delivery rooms as quickly as possible.

So why does it matter if practitioners are mean, taciturn and overworked? Politicians would say all that matters are the results - baby and mother alive at the end of the day. There. Job done. At what cost? If someone behaves horribly to a woman in labour, her levels of cortisol go through the roof. Cortisol is an antagonist to oxytocin and oxytocin is needed for strong contractions. This means when the woman is stressed by an unrelenting battleaxe in the labour ward, her contractions turn off or become weaker. Labour is lengthened, or stops altogether and then the artificial oxytocin is started. While research is still out about the safety of this particular drug, practitioners know it has a terrible effect on the baby. When syntocinon is used, we have to strap on a continuous fetal heart monitor (CTG) because the effect on the baby has to be measured to determine if the benefit continues to outweigh the risk in a given situation. Research proves that the use of the CTG increases the likelihood of Caesarean section. Again politicians say big deal: our caesarean section rates are acceptable, have you not seen our infant mortality rate?

Caesarean sections are a much larger drain on the system than vaginal deliveries. Emerging research is showing vaginal birth is the key to our immune systems as adults. Without vaginal birth, non-communicable diseases will bankrupt our health system. Not to mention, emergency caesareans can leave mothers and fathers mentally and emotionally scarred. Fewer caesareans would also leave more money to address the atrocious care ratios.

The HSE promises they are looking for strategies for reducing the caesarean rate in Ireland. How about starting with anger management and communication training for all the midwives and Ob/Gyns?

For more information on maternity services in Ireland, please see www.42weeks.ie

To read real stories of the Irish maternity services, please see here: 'Shout Back - Your Say'

and here: AIMS Ireland

AIMS Ireland AGM: Saturday December 7, 2013

                       AIMS Ireland AGM

When:  Saturday, December 7, 2013
Time:    2:30PM
Where: Teacher's Club, Parnell Square, Dublin (across from Rotunda)
Directions: http://www.clubnamuinteoiri.com/

 Speakers

 
"Daughters of the Revolution, Theatre Workshops" - Kate Harris of 4 Elements Theatre Company

 
AIMSI member, Nuala Hoey is speaking about her personal experience of birthing decisions and positive birth choice.

 
"Neglecting Reproductive Autonomy : A legal analysis of consent during pregnancy and childbirth in Ireland" - Barrister, Mary Kirwan


AIMS Ireland AGM

* 2012-2013 Committee Annual Report
* Proposed Motions and Business
* Election of Committee Roles

AIMS Ireland Members: Proposed Motions and Business

Any proposed motions or business for AIMS Ireland in the upcoming year are to be submitted by email to Chair@aimsireland.com by 5pm, Thursday December 5th.

 Committee Roles

AIMS Ireland need to elect all committee roles at the AGM. We are currently taking nominations.

To be eligible for Committee Roles with AIMSI you must fit the following:

* member of AIMS Ireland
* cannot be a medical professional
* be available and willing to commit to a year in elected position

AIMS Ireland Committee Roles:

Secretary
Treasurer
Membership
Press Officer
Women's Support and Information Aide
Events/Fundraising
** Chair
** Vice Chair

** Chair and Vice Chair may be split as Co-Chair if preferred and agreed with committee


AIMS Ireland are also seeking assistance with non-committee roles in a voluntary capacity with issues such as event planning, fundraising assistance, campaigns, surveys/research, graphic design (infographs), video production, etc. If you have skills you would like to contribute to AIMSI please contact us at info@aimsireland.com

 Membership to AIMS Ireland is €20 for a year. Membership entitles you to membership of a private AIMSI online facebook group and election/vote of committee roles and motions. Membership fees go back into women's support services. Please Join Us!! http://www.aimsireland.com/join/?topic=join

Fundraising/Donations to AIMS Ireland go directly to AIMS Ireland research, support services and campaigns. If you would like to organize an event in the aide of AIMS Ireland, please contact us at info@aimsireland.com

AIMS Ireland receives no outside funding - fundraising, donations, and membership provide our sole financial support and go straight back to campaigns and women's services.

Annual Organizational and Financial Reports from AIMSI for 2012-2013 will be made available at the AGM.

Our amazing Treasurer, Alcarine Power, has recently resigned following 5 amazing years with AIMSI. We are so sad to see her go and will miss her immensely.

 Thank You,

AIMS Ireland Team

AIMSI 3 PQ's regarding Misoprostol Dosage Guidelines & Bimbo Onanuga

QUESTION NOS:  638 to 640

DÁIL QUESTIONS addressed to the Minister for Health (Dr. James Reilly)
by Deputy Clare Daly
for WRITTEN ANSWER on 19/11/2013  

 
 *  To ask the Minister for Health if all 11 recommendations following Health Service Executive investigations following the death of a person (details supplied) including number seven, have been fully implemented in the Rotunda Hospital, Dublin.

                                                                                          - Clare Daly T.D.

For WRITTEN answer on Tuesday, 19th November, 2013.

Details Supplied: Bimbo Onanuga

*  To ask the Minister for Health if the Rotunda Hospital, Dublin, have updated their guidelines on the management of intrauterine death to include lowering the dosage of Misoprostol to reflect recommended standards in RCOG.

                                                                                          - Clare Daly T.D.

For WRITTEN answer on Tuesday, 19th November, 2013.

*  To ask the Minister for Health the reason the RCPI/IOG guidelines regarding the use and dosage of misoprostol were not implemented, as per Health Service Executive recommendations.

                                                                                          - Clare Daly T.D.

For WRITTEN answer on Tuesday, 19th November, 2013.

Details Supplied: (Note the October 2013 published HSE guidelines remain unchanged and do not reflect what was recommended following the death of Bimbo Onanuga)?

 
REPLY.
As I responded to the Deputy in my reply of 13th October last, I have been advised that the circumstances surrounding this patient's death were investigated by the HSE under the National Incident Protocol following which 11 actions were recommended.  I have been informed by the HSE that the Rotunda Hospital has now implemented all 11 recommendations.  

In relation to the other issues raised by the Deputy, as these are service matters, I have referred them to the HSE for attention and direct reply.

Minister for Health James Reilly rejects calls for a HIQA review into the death of Bimbo Onanuga

AIMS Ireland last week welcomed the verdict of medical misadventure in the Coroner's Court following the inquest into the death of Bimbo Onanuga in the Rotunda in March 2010.

Bimbo Onanuga died following a medical induction with Misoprostol/Cytotec 29+ weeks into her pregnancy due to the intrauterine death of her baby. Eyewitness accounts describe a catalogue of errors and failures to provide basic care to Bimbo that day.

Following the coroner's verdict, supporters (academics, medical professionals, oganizations and friends) of Bimbo Onanuga, including AIMS Ireland, called for a HIQA review into the failures of basic care and treatment Ms Onanuga received in the Rotunda Hospital in March 2010.

AIMS Ireland reported that there were "Echoes of both Savita and Tania McCabe once again at inquest of Bimbo Onanuga today..." More: http://nocountryforpregnantwomen.blogspot.ie/2013/11/a-matter-of-public-interest-aimsi-calls.html

A HIQA review would be in line with actions taken by the Minister following the death of Savita Halappanavar.

A PQ (Parliamentary Question) was put into the Dáil to the Minister for Health, James Reilly by Deputy Clare Daly.

The Minister has rejected calls for a HIQA review - denying an investigation into the systematic failures of care and treatment Bimbo Onanuga received in the Rotunda Hospital in Dublin.

AIMS Ireland is extremely concerned by the lack of accountability and continued significant efforts to hide the circumstances of Bimbo’s death.

It is astonishing that  given the similarities of failures on record, the Minister has chosen to act, calling for an independent HIQA review into one woman's death, while refusing the other.

The PQ and Reply:

QUESTION NO:  22

DÁIL QUESTION addressed to the Minister for Health (Dr. James Reilly)
by Deputy Clare Daly
for ORAL ANSWER on 13/11/2013  

 
 To ask the Minister for Health if he will order a Health Information and Quality Authority investigation into the circumstances of the care of a person (details supplied) in line with the HIQA investigation into the death of Savita Halappanavar.

                                                                                         Clare Daly T.D.

Details Supplied: An inquest into the death of Ms Bimbo Onanuga concluded on 5 November with a coroner’s verdict of medical misadventure. In the course of treatment in the Rotunda Hospital on 4 March 2010, Ms Onanuga suffered a catastrophic incident and was transferred later that day to the Mater Hospital where she died. The details of her case as laid out in the Coroner’s Court raise fundamental issues about her care and treatment. Will the Minister order a HIQA investigation into the circumstances of Ms Onanuga’s care, in line with the HIQA investigation into the death of Savita Halappanavar.?

 
REPLY.
I would like in the first instance to offer my sympathies to the family involved in this very unfortunate case.

I have been advised that the circumstances surrounding this patient's death were investigated by the HSE under the National Incident Protocol following which 11 actions were recommended.  I have been informed by the HSE that the Rotunda Hospital has now implemented all 11 recommendations.  

I am advised by my Department's Chief Medical Officer that it is not necessary nor is it appropriate for me to request the Health Information and Quality Authority (HIQA) to undertake investigations in a case such as this which has been adequately investigated under the HSE's incident management procedures.  

It is important to state that maternal and peri-natal health statistics indicate that Ireland continues to be a very safe country for a woman to give birth and our safety record compares favourably with other developed countries.

AIMS Ireland calls for a HIQA review into the Death of Bimbo Onanuga and the Catalogue of Sytematic Failures in Basic Care.

AIMS Ireland last week welcomed the verdict of medical misadventure in the Coroner's Court following the inquest into the death of Bimbo Onanuga in the Rotunda in March 2010.

Bimbo Onanuga died following a medical induction with Misoprostol/Cytotec 29+ weeks into her pregnancy due to the intrauterine death of her baby. Eyewitness accounts describe a catalogue of errors and failures to provide basic care to Bimbo that day.

AIMS Ireland are calling for a HIQA review into the death of Bimbo Onanuga

A Catalogue of Sytematic Failures in Basic Care


* Despite conflicting reports, Bimbo Onanuga disclosed her full medical history on booking at the Rotunda. Women are encouraged to disclose full histories in order for their care team to pre-empt any complications which may arise following some medical histories. Gynaecological procedures and investigations, abortion, surgery, injury, previous mode of birth, and more are all histories in which can affect the care paths of women.

* It is the responsibility of maternity providers to ensure individual assessment and appropriate care to women, regardless of her history. It is also the responsibility of maternity providers to inform themselves of women's previous history in order to develop the safest care plan for each woman taking into account her medical history, current pregnancy, her concerns, informed choice, and potential complications.

* It is the responsibility of care providers to listen to concerns raised by women and their families. AIMS Ireland encourage women and their birth partners to express concerns, unusual sensations or pain, if something doesn't 'feel right', and side affects to their care providers. It is the duty of care providers to listen.

* It is the responsibility of maternity providers to ensure that all staff are fully trained on how to provide basic clinical observations and record them in a timely fashion.

Bimbo's failure of basic care

* Bimbo Onanuga was nearly 30 weeks pregnant and was medically induced with Misoprostal on the Gynaecological ward rather than the labour ward.

* One of the principal carers for Bimbo Onanuga during the time of her induction on the gynaecological ward of the Rotunda Hospital was a nurse, not a midwife. The necessary clinical skills for diagnosis and treatment of labour, induction, complications, and basic issues such as experience in palpitation of the uterus are outside the scope of practice for a nurse and require the professional skills of a midwife.

* Bimbo was administered two doses of Misoprostol of 200mcg at three hour intervals - one vaginal and one oral. Recommendations from RCOG state that (I) induction of labour using Misoprostol is not recommended (II) Misoprostol should only be given orally, not internally (III) recommended dosage is 50-100mcg by four hours.

* Misoprostol is an off-label drug. This means that staff are not required to record adverse outcomes relating to this drug. Misoprostol has been linked to uterine hyperstimulation  and uterine rupture in women with scarred and unscarred uteri. There have been recorded instances of rupture in first time mothers whom were given Misoprostol for induction of labour.

 * Bimbo reported to be in 'constant' pain. It is reported that Bimbo was told as the pain was constant, rather than waves of contractions, she was not in labour. Concerns raised by Abiola that Bimbo was experiencing constant and severe pain were reportedly ignored and midwife Shiela Lynch is reported to have said she was exaggerating. Constant and severe pain is unusual and suggests something is out of the normal progression of induction. This was not recognized as 'abnormal'.

* Bimbo's partner Abiola reported that Bimbo could not breath or talk. His attempts to raise the alarm were not followed through.

* On Bimbo's collapse, it was Abiola who first initiated CPR

* It is reported that on Bimbo's collapse the available machine for measuring blood pressure appeared not to be working. Rather than taking the blood pressure manually, staff spent time attempting to get the machine working again.

 * On Bimbo's collapse the medical team prepared for an emergency Caesarean Section. However the bed was too large to fit through the door of the Gynaecological ward and subsequently, an immediate Caesarean Section was instead performed on her bed on the Gynaecological ward.

* There are concerns relating to the medical notes the day Bimbo died. Notes were retrospective, out of sequence, were incomplete, and clinical observations were not recorded.

* Following Bimbo's death investigations were undertaken very quietly through the HSE. At no point was any information made public. Bimbo's death did not receive a full HSE inquiry. Bimbo's death did not receive a public apology. Following 3 PQs, recommendations into HSE investigations into Bimbo's death were released.

* Following the PQs, the HSE released a statement expressing its sincere sympathies to the family involved. However, the family were not contacted directly and are unaware of the statement

* The initial request for an inquest into the death of Bimbo Onanuga was denied by the Coroner ruling she died of natural causes. This was later reviewed and an inquest was granted.


  These are the recommendations from the HSE following investigations into Bimbo Onanuga's death:

1. The need to identify clinical pathways relating to management of women with an intrauterine death in third trimester to complement existing medical management policy.

2. The Guidelines for Medical Management of Intrauterine Death should be revised in line with a review of the medical literature.

3. Details of all patients for Induction of Labour, regardless of place of induction should be centrally documented.

4. This recommendation cannot be disclosed as it contains personal, private, sensitive and confidential information relating to the individual patient.

5. Develop a brief operational outline of the Gynaecology Department to assist staff who are sent there on an occasional/intermittent basis.

6. Due to the complexity of work, there is a need for an updated training needs analysis of all midwifery and nursing staff on the gynaecology ward.

7. There should be a designated individual with responsibility for coordinating, monitoring and auditing the Basic Life Support attendance and Advanced Life Support Skills attendance, ideally a designated Resuscitation Training Officer.

8. An Obstetric Early Warning System should be introduced and evaluated.

9. Install additional phone lines in the ward.

10. A review of the possibility of emergency call bells or designated phones for emergencies in each room should be carried out and measures taken to address this.

11. Hospital wide analysis of all doorways in clinical areas to establish the feasibility of moving a bed in a critical event.

The Rotunda is reported as having changed their guidelines for the management of intrauterine death and fully implementing the 11 HSE guidelines.

However, it is important to note that guidelines on the HSE/RCPI/IOG websites (revised October 2013) are unchanged and recommend the same management guidelines which were in place the day Bimbo died; Misoprostol dosage and scheduling 200mcg by 3 hours.

AIMS Ireland call for a full HIQA review into the death of Bimbo Onanuga and review of guidelines for Management of Intrauterine Death to come in line with those of the UK and RCOG

A Matter of Public Interest - AIMSI calls on transparency & accountability following details into death of Bimbo Onanuga. Press Release: Echoes of both Savita and Tania McCabe once again at inquest of Bimbo Onanuga today, according to maternity advocacy group. AIMS Ireland calls for accountability and clinical review following verdict of misadventure as a matter of 'public interest'

Echoes of both Savita and Tania McCabe once again at inquest of Bimbo Onanuga today, according to maternity advocacy group

 

AIMS Ireland calls for accountability and clinical review following verdict of medical misadventure

Press Release:

(Tuesday, November 5, 2013) The Association for Improvements in the Maternity Services Ireland (AIMS Ireland) today petitioned for accountability, a review into clinical care practices, and national guidelines on the use of the drug misoprostol (cytotec) following the verdict of medical misadventure returned at the inquest into the death of Bimbo Onanuga at the Dublin Coroner’s Court today. Bimbo Onanuga's inquest has once again exposed underlying critical flaws in basic clinical care within an Irish maternity unit, echoing concerns raised following reports into the deaths of both Savita Halapanavar and Tania McCabe.

The HIQA report into the death of Savita Halapanavar published last month found ‘The most basic means of identifying any patient at risk of clinical deterioration is to observe the patient’s general condition and regularly monitor and track their clinical observations. This should be a basic component of caring for any patient.’ Abiola Adesina, Bimbo Onanuga’s partner, told the inquest yesterday that Bimbo was rolling around and in constant pain following admission to the Rotunda Hospital in March 2010 and that attempts to raise concerns were disregarded as a normal progression of labour. Bimbo, who had a number of risk factors in relation to the intrauterine foetal death, had received misprostol (cytotec) to induce labour.

Krysia Lynch, Co-Chair of AIMS Ireland, commented "The parallels between Savita, Tania, and now, Bimbo, are staggering. We see once again a catalogue of basic fundamental failures from a lack of documentation to basic clinical observations. Most crucially, we once again see a comprehensive failure by health care providers to listen to women. This is a reoccurring complaint from women contacting AIMS Ireland - they do not feel their concerns are acknowledged or listened to. In a critical medical event, this can be the difference between recovery or death."

On the issue of the use of the drug cytotec, Lynch added "Misoprostol has been linked to uterine rupture  in women with and without scarred uteri and is not recommended for use in induction. The Royal College of Physicians in Ireland (RCPI) guidelines on cytotec use sit outside those of the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK, which raises a red flag and unanswered questions. AIMS Ireland is calling for full accountability and transparency. We ask the Rotunda, did Bimbo receive the basic care, monitoring and a care plan consistent with her clinical needs? Was she appropriately and effectively monitored given the use of the drug misoprostol? Has the Rotunda taken proper and appropriate steps to update staff about the use of the drug misoprostol? Why do their guidelines continue to sit outside those of the RCOG? We also raise concerns regarding queries to the disclosure of Bimbo's previous termination at the inquest. Our sources have revealed that this history was fully disclosed and this information was available to care providers. From the onset, the Rotunda hospital has made attempts to conceal information relevant to the case - including a litany of errors, mishaps, and failures of basic care to Bimbo. We publicly call on the Rotunda to clarify on these matters. This is a matter of public interest."

Concluding, Lynch said “We very much welcome this verdict of medical misadventure from the Coroner Brian Farrell. Despite significant efforts to hide the circumstances of Bimbo’s death, the truth is now on public record. After fighting for many years for this inquest and to have her story heard, Bimbo’s family is finally vindicated.”

ENDS

 

For further information, contact:

Krysia Lynch, AIMS Ireland 087 754 3751

Jene Hinds Kelly, AIMS Ireland 087 681 9095

UK & Irish guidelines on the use of Cytotec/Misoprostol for medical induction of labour after an intrauterine foetal death (IUFD)

RCOG Guideline

The RCOG Green-top Guideline No.55 Late Intrauterine Fetal Death and Stillbirth, published in October 2010 recommends the use of low doses of misoprostol (50 or 100 micrograms depending upon gestational age) when inducing labour:

“The RCOG is aware that protocols employing much larger doses of misoprostol are still being employed in the UK, with consequent potentially associated adverse effects. Each maternity unit is advised to review their protocol for the management of induction of labour under these circumstances and to adopt the recommended misoprostol dosaging. Currently, misoprostol is only available in the form of a 200 microgram tablet; however the required dosage of 50 or 100 micrograms can be obtained by cutting the tablet or by dilutional methods. Your hospital pharmacist will be able to assist you with this if necessary.”
http://www.rcog.org.uk/...

RCPI Guidelines

Royal College of Physicians I reland (RCPI) Guideline: #4 Intrapartum fetal heart rate monitoring - Appendix 4:
http://www.rcpi.ie/article.php?locID=1.5.71.492

On the day of diagnosis of IUFD
Mifepristone 200mg PO
36-48 hours after diagnosis
24-34 weeks Misoprostol 200mcg PV followed by 200mcg PO 3 hourly x 4 doses
>34 weeks Misoprostol 100mcg PV followed by 100mcg PO 3 hourly x 4 doses
A second course may be started after 24 hours and with medical review

Cytotec (Misoprostol) drug label: http://www.rxlist.com/cytotec-drug.htm

Cytotec/Misoprostol - Research

A 2006 Cochrane Review of Misoprostol for induction showed that while oral use of Misoprostol was shown to be an effective induction method, this is not without increased risks. Misoprostol increases risk of uterine hyperstimulation. The uterus may contract too frequently (more than five contractions in 10 minutes), the contractions may last too long (2 minutes or more per contraction), or the uterus may not relax enough between contractions. A casual relationship between uterine rupture and use of Misoprostol in scarred and unscarred uteri is acknowledged, Cochrane notes this requires further investigations but is a cause for concern.

Unfortunately, it is almost impossible to show true risks of misoprostol in induction of labour, because according to the Cochrane review (2010) - "It is not registered for induction of labour, and has therefore not undergone the systematic testing for appropriate dosage and safety required for registration".

The 'off label' use makes it a drug that has never been through rigorous clinical trials and it is, by proxy, not subject to reporting of adverse reactions or outcomes.

 

How many maternal deaths invoving Cytotec have to happen before it is removed from 'off label' use?

 

We'll never know, because no one records Cytotec as a cause or a factor in these deaths.

In the inquest of Bimbo Onanuga, Rotunda's Sam Coulter-Smith is on record as saying:


"Dr Coulter-Smith said there are risks when using misoprostal if there has been previous scarring or perforation of the uterus, but there was nothing in Ms Onanuga's medical notes to indicate such a risk." (RTE news)

"A post-mortem examination later revealed that there was scarring due to a previous termination of pregnancy. But that knowledge came only in hindsight." (RTE news)

AIMS Ireland Counter-Points:

* Undisclosed sources to AIMS Ireland report that Bimbo Onanuga was upfront about her previous termination and report that this information is in her booking notes.

* The occurrence of uterine hyperstimulation and instances of uterine rupture following Misoprostol have been reported in women with scarred and unscarred uterus.

From the Cochrane Review 2010:

"There have been several reports of uterine rupture following misoprostol labour induction with and without previous caesarean section (Bennett 1997; Sciscione 1998; Blanchette 1999; Matthews 1999; Khosla 2002). One unpublished case of uterine rupture occurred in a nulliparous woman following misoprostol use (EM Smith, personal communication). At term plus 12 days she received misoprostol 100 mcg vaginally. After six hours her cervix was found to be 7 cm dilated, and she progressed to full dilatation within a further 70 minutes. Fetal distress was suspected. Ventouse application produced no descent, so delivery was effected by caesarean section. The infant showed no signs of life at birth. After resuscitation, life was sustained for a few hours only. A posterior uterine tear arising from the cervix and spiraling up the posterior aspect of the uterus was discovered and repaired. because such uterine tears are rare in nulliparous women without prolonged labour or syntocinon use, a causal relationship with the use of misoprostol must be considered."

 

 

 

And:

 

 

"In a subsequent abstract (Merrell 1996), they described labour inductions with vaginal misoprostol in 345 women with live fetuses and 86 with intrauterine deaths. There was one unexplained maternal death; two uterine ruptures, one of which followed a previous caesarean section; eight caesarean sections for fetal distress and one for uterine hyperstimulation; and 10 perinatal deaths."

 

 

See More: Vaginal misoprostol for cervical ripening and induction of labour - Cochrane 2010 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000941.pub2/full 

 

Matter of Public Interest

 

The Rotunda made significant efforts to conceal the circumstances in this case and the initial request into an inquest into Bimbo's death was denied. It was only after constant pressure and support from whistleblowers, advocacy groups, politician Clare Daly who put forward the PQs, and Bimbo's amazing and strong family that the coroner granted an inquest and the lithany of errors and failures of basic clinical care contributing to the circumstances surrounding Bimbo's death began to emerge. It is a matter of public interest that the details of these circumstances are acknowledged.

AIMSI is currently finalizing a catalogue of these errors to be published later today.

 

 

 References:

RTE News: Medical misadventure ruling at Onanuga inquest http://www.rte.ie/news/2013/1105/484745-inquest-bimbo-onanuga/