Rotunda Master calls for new termination law

Dr Sam Coulter Smith, in an interview with Irishhealthpro.com, has described as "crazy" the current situation whereby women in cases where they are carrying infants with fatal foetal abnormalities are forced to travel to the UK for terminations.

Referring to current pressures on facilities at the Rotunda, Dr Coulter Smith warned that having a baby "shouldn't be about a conveyor belt".

The Rotunda Master also pointed out that screening services for congenital abnormalities during pregnancy should be more widely available. He said there was inequality of access to these services in Ireland at the moment depending on where the mother lives.

Dr Coulter Smith also said the failure of the plan to build the national paediatric hospital at the Mater site and move the Rotunda there was a "fantastic opportunity missed". He said the only option now was to try to expand the under-pressure facilities at the Rotunda on its current site and hope that the funds will be available some time in the future for it to co-locate with a major acute hospital.

He also revealed that there were two maternal deaths recorded at the Rotunda last year, following three deaths recorded the previous year. Both deaths were classified as "indirect" maternal deaths, linked to pre-existing conditions and not related to direct obstetric causes.

Also in 2012, a pregnant woman who was originally booked at the Rotunda who then travelled to a UK clinic for an abortion subsequently died in London from complications of the termination. This death, however, has been included in UK figures rather than in the Rotunda's statistics for the year, Dr Coulter Smith said.

Dr Coulter Smith also warned that Health Minister James Reilly's reorganisation of hospital services into groups and ultimately independent trusts could lead to financial management being put ahead of patient safety if medical staff were not involved in a meaningful way in the running of this new system.

Rotunda under pressure

Dr Coulter Smith said staff and facilities at the Rotunda are under severe pressure.

"We are looking after 2,500 more mothers a year than we were in 2002, so that's a dramatic increase. The numbers have been rising at around 4-5% a year - the overall rate of increase, however, has recently slowed down.

"We have recently had a 2% drop in deliveries but we are still dramatically busier than we were a number of years ago. Three of the past four years have been the busiest in the history of the hospital. This puts an awful lot of pressure on the system.

"We don't have anything like the number of staff that we need to look after this number of patients. If you look at staff-patient ratios and internationally-recognised best practice ratios then the midwife to patient ratio should be about one to 25 but we are currently about one to 50. The consultant to patient ratio should be around one to between 300 and 500 for a tertiary referral hospital but we are one to 1,000."

Dr Coulter Smith said the hospital has to date never capped its number of maternity bookings. "If the activity were to increase any further, however, than it's certainly something we would have to reconsider. Essentially what we need is a bigger facility and greater staff numbers to deal with activity levels."

Quality of care affected

Dr Coulter Smith gives a practical example of the type of pressure the Rotunda is under: "Just after Christmas last year we had 42 deliveries in one 24-hour period and that was in nine delivery rooms. So those rooms were turned over extraordinarily quickly during that time. About three or four weeks ago we had 13 deliveries in three-and-a-half hours. That is about one delivery every 20 minutes. That is really the problem, because when you hit that level of activity it is very hard to provide women with the quality of service that they would like.

"Having a baby shouldn't be about a conveyor belt, it should be about quality time, one-to-one midwifery care, time to relate to the midwife, and then time to afterwards to have quality time with the baby, assistance with breastfeeding if that's what the women chooses to do, etc.

"The fact is that if you are pushing people through the system then getting access to the labour ward, access to an epidural when you want it, appropriate pain relief when it's requested and not at the last minute... they are the sort of issues that arise when the hospital gets extremely busy."

Is safety ever compromised in these situations?

"When you get peak levels of activity, if everything is going normally then that's fine but if you get two or three things going wrong at the same time, and obstetrics by its nature is unpredictable... if you get two or three emergencies, where emergency interventions are required at the same time, then you can really get very stretched and pushed in terms of who you deliver first."

Would these pressures ever impact on maternal mortality?

To date, these pressures have not put mothers at risk, Dr Coulter Smith says. "I don't think we have ever had a situation where a mother's life has been at risk because of pressure on resources." However, he said it was of concern that neither the Rotunda nor the other Dublin maternity hospitals has an intensive care unit and none of them has immediate access to interventional radiology.

"Those services are associated with our nearest adult hospital, so over the years we have developed very strong links with our adult hospital neighbours. But any modern 21st century maternity service should be co-located with an adult hospital so that can provide it with all of the services that it needs to keep things at their best quality."

Will the Rotunda ever move to a new site?

"That's the ideal solution. You should be co-located with an adult hospital to provide all the facilities to support your sickest mothers and a paediatric hospital to supply all of the needs for your complicated sick babies."

With the plan to move to the Mater now scrapped, how can that be achieved?

He admitted that co-location with an adult hospital now seems a long way off, following the shelving ot the plan to relocate the Rotunda on the Mater site, once it as decided that the paediatric hospital would not be built there.

"We are now in one of the new hospital groups with Beaumont and Connolly and the other hospitals in the north east. Right now Beaumont doesn't have the space for a maternity unit. Connolly has the space, but neither hospital has the range of services and the expertise associated with maternity services that we currently have at the Mater.

"The Higgins report on hospital reorganisation very clearly identified the need for the Rotunda and the Mater to maintain an extremely close relationship. Currently the only option for us is to have that association with the Mater. At the moment there is no plan for relocation because despite all the plans and reports that have been issued over the last number of years on this, none of them have been acted upon.

"The issue we now face is there is a lot less money in the system and achieving that co-located facility is going to be a real challenge. The only option we have right now is to try and expand where we can on the current site, and this is what we are now doing, while hoping that in future money will become available and we can ultimately co-locate.

"The Mater plan was a fantastic opportunity missed. The Mater adult hospital was essentially rebuilt to allow it to plug in to a children's hospital and a maternity hospital on-site.

"True co-location means that you don't have to put a sick patient in an ambulance and transfer them elsewhere - it means you can move them down the corridor through a door and they are into the specialist area in which they need to be treated."

Maternal deaths/clinical results

Dr Coulter Smith revealed that there were two maternal deaths recorded at the Rotunda in 2012, following three deaths the previous year.

Maternal mortalities can be classified as direct where there are direct obstetric causes, or indirect where they are linked to pre-existing conditions.

"In 2011 we had three maternal mortalities - one of those were direct, the other two were indirect. In 2012, there were two maternal mortalities that would be included in our figures. Both these were indirect mortalities, where there were underlying conditions. There was a third death but that would be included in UK figures. This was the case of a woman who went to the UK for a termination and unfortunately and tragically died as a result of a complication of that termination. She booked at the Rotunda and then chose to go to the UK."

Despite the relatively high number of maternal deaths at the hospital in recent years, Dr Coulter Smith says this does not necessarily indicate a trend. "Maternal mortalities are rare; they are almost always one-off events. You rarely get the same set of circumstances occurring twice. It is often difficult to establish trends. You need to look at much larger numbers to see what those trends are.

"Our perinatal mortality rates are very good. The majority of these mortalities are due to a combination of extreme prematurity and infection. The perinatal mortality rate in larger infants is is thankfully very small and that is down to the dedication and skill of the staff within the hospital."

Staff shortages

Dr Coulter Smith says despite the hard work of staff and overall good results being achieved, he has never seen staff morale so low.

"The general economic situation has meant that the best young graduates are looking elsewhere and you can see this among doctors, midwives and nurses. People are leaving, are going abroad, and that is a serious concern. There has been a huge fall-off in the number of people applying for consultant posts in Ireland. It's a combination working conditions, the atmosphere within the service and the salary that they can achieve. I think morale among staff is as low as I have ever seen."

Birthing options

"We have expanded the model of care to include a more community-based service. We have hospital-run clinics out in the community. We also have the Domino service where women can receive antenatal care in their own homes and that is great but it is quite labour intensive. If we had more midwives in the system this is something we could expand on and improve on but currently it's difficult.

"As regards home births, it would be ideal in my view if the governance of the home births system lay within the hospital setting so that hospital midwives would go out and deliver care to women in their homes. I would have some concerns over the structure there at the moment. You need numbers of midwives within the system to provide any expanded home birth service and currently those numbers just aren't there."

Developments in maternity care

"The big advances that have happened are in terms of fertility services which have improved, but assisted fertility is still something that is not State-funded, and I think that is a major issue and a gap in the system. One of the other big advances in maternity services has been in foetal medicine."

However, Dr Coulter Smith says there is inequity of access around the country to screening services for congenital foetal abnormalities.

"Congenital anomaly screening has expanded hugely but the screening service that is available in the bigger hospitals is not universally available throughout the country. This service can give people reassurance and also can pick up problems antenatally so that plans can be put into place. For example, with congenital heart problems, plans can be put in place to treat these babies when they deliver. Lack of these screening services in outlying units means that women don't have access to those services so you will get anomalies that will slip through the system.

"In some cases, if it is a lethal issue you will not be able to do anything about it, but if screening is available, it allows people to make choices as to what they want to do in relation to that particular anomaly. In cases where there is something that can be done, then it allows plans to be made at an early stage."

The abortion debate

"I think we still don't know what the impact of the Protection of Life During Pregnancy legislation is going to be. However, I think from the point of view of very sick mothers, people who have life-threatening conditions that are complications of pregnancy or where people have other issues that complicate pregnancy, the care of those women will continue, certainly in this hospital, in the way that it always has.

"The protection of the life of the mother is something that is paramount. Obviously, every effort is made to protect the life of the child but in a situation where if the mother is going to die then the baby is going to die then we have obviously got to do everything possible to save the life of the mother. I never believed the legislation was going to affect that particular situation."

Fatal foetal abnormalities

"This issue will require separate legislation-that is something that does need to be addressed. The current situation is crazy. Ultimately we will come around as a society to that but it is an awful shame that we have this crazy situation where women who are carrying babies who have a fatal foetal abnormality are forced to travel to the UK."

Concerns on hospital groups

Dr Coulter Smith has concerns about Health Minister James Reilly's move to set up hospital groups and ultimately, independent hospital trusts 

"The idea behind the new system is that the hospital groups will ultimately become independent trusts. If you are planning to model the Irish services on a UK trusts model then you have got to look at the flaws within the UK system. You have got to look at is the lessons that have been taken from what happened with the hospital trust in Mid-Staffordshire. In the UK model, all the focus seems to be on financial management and you can see what happened in Mid-Staffordshire (where there were excessive numbers of patient deaths). In that case, clinical outcomes were deemed less important than financial management, and I believe that a number of other trusts in the UK are in similar situations. 

"I think we need to be very careful about our hospital group model. If you don't have senior clinicians at the top table when it comes to managing those services then the concern would be that the focus is going to be on financial management.

"I think the maternity services in Ireland have been been a flagship for the Irish health service in producing world-class results out of what you couldn't possibly call world class facilities.

"I think it is because of the good governance system we have in the maternity hospitals that the clinical results have been so good. We are now talking about those governance systems being incorporated in some way into groups. I suppose I could be accused of being suspicious of change but if you don't import what is good and take it with you on the change journey you are at risk. At the end of the day, running health services is all about clinical outcomes."