The long awaited HIQA report on its investigation into Portlaoise Hospital has highlighted failures over a number of years by the HSE at a national, regional and local level to decisively address numerous clinical governance and management issues.

According to HIQA, this impacted upon the quality and safety of services provided at Portlaoise Hospital. The HIQA inquiry was initiated in the wake of the unexpected deaths of five infants at the hospital, and followed on from a highly critical report on these adverse events by the Department of Health last year.

The damning HIQA report, published today, says the experiences of patients and their families outlined in its report 'highlighted significant deficiencies in the delivery of person-centered care at the hospital'.

This care fell well below the standard expected in a modern acute hospital, HIQA Chief Executive Phelim Quinn said.

HIQA said had the findingsand recommendations of previous inquiries and reviews into safety incidents at Portlaoise been acted upon, the risks to patient safety and quality could have been substantially reduced.

Among the recommendations in the HIQA report is the creation of an independent patient advocacy service to ensure that patients' reported experiences are recorded, listened to and learned from, and reports published.

"Lessons learned should be shared between hospitals within the new hospital groups, between hospital groups and nationally throughout the wider health system," HIQA said.

The HIQA probe report says the hospital viewed itself as operating as a model-3 hospital - one which provides the full range of acute services to patients presenting with all manner of injury and illness, including life support.

"However, services at the hospital were neither governed, resourced nor equipped to provide this level of care. This was despite the fact that the HSE was in possession of information that indicated that its own clinical care programmes had expressed concerns about the quality and safety of acute and general medical services, paediatrics and surgery," the report says.

The HIQA probe looked at other aspects of Portlaoise Hosital servives besides maternity care. The report says the hospital continues to provide surgical services where there are low numbers of complex surgical cases, despite the fact that two previous HIQA reports had identified clinical risks in these types of services.

Phelim Quinn added: "We believe that such a clinical network has the capacity to facilitate a common system of governance, the capacity for medical, midwifery and other staff to rotate between the two sites and more importantly, that the right patient is treated in the most appropriate clinical environment.

Commenting on the report, HIQA also said it believed it is vital that a national maternity strategy is urgently developed in order to ensure that the profile and models of maternity services meets the needs of women across the country.

It welcomed the Minister for Health's recent announcement on the development of the Maternity Strategy Steering Group.

"In addition, HIQA, in conjunction with the relevant patient, clinical and professional organisations will develop draft standards for maternity services in Ireland for public consultation. These will be a part of the Authority's National Standards for Safer Better Healthcare."

In light of the findings of its Portlaoise probe, HIQA has made eight recommendations which it says must be implemented to ensure that risks and deficiencies identified are addressed at both local and national level to ensure the delivery of safe and consistent patient care.