What does the latest report on serious problems in maternity services at Portiuncula University Hospital tell us? In my view, it provides irrefutable evidence that the systemic issues flagged in the 2018 Walker report have not been effectively addressed. That report warned that “without fundamental changes in process and training”, the tragic incidents investigated would happen again. This latest report, which reviews five adverse perinatal outcomes, demonstrates that the measures put in place after 2018 have failed.
“It is disappointing,” the authors observe with some understatement, “that the clinical issues identified previously in 2018 have recurred.”
Taken together, the two reports make an unanswerable case that safe maternity services are no longer viable at Portiuncula. While there is scope for antenatal clinics to continue, the unit is no longer fit for purpose for women to give birth there.
The latest report documents in the starkest terms the factors that make this conclusion inescapable.
Trump reaps $50bn tariff haul as world ‘chickens out’
Irish tech worker detained by immigration agents in US for 100 days: ‘I didn’t know when I was getting home’
Drury Street hotel plans for vacant office block hit by local concerns about on-street drinking
Sharp exchanges follow Alan Shatter’s comparison of occupied territories trade ban with 1930s Germany
The first issue is the number of deliveries each year. The report is clear that a maternity unit of “such size cannot provide the full range of maternity and newborn services”. That is a clear red flag.
[ Families at centre of Portiuncula review call into question viability of serviceOpens in new window ]
The most recent figures show that around 1,400 babies are born at Portiuncula each year. Critically, however, the extraordinarily high Caesarean section rate of 42 per cent in 2024 (double the rate of Scandinavia) means that nearly 600 babies were delivered surgically. In practical terms, this amounts to 50 sections per month, around 12 per week, thus not quite two per day. Some of these would have been scheduled, some would have been emergencies.
Vaginal births numbered just over 800 last year – that is, around 67 per month, or two to three per day. Since vaginal deliveries occur over 24 hours, daily numbers are typically variable, so that Portiuncula would have experienced some days with perhaps five or six deliveries, while other days there may have been none. These numbers are not conducive to maintaining the skills and experience of the obstetric and midwifery staff. This is a risk factor for mothers and their infants.
The HSE’s proposed solution – to move high risk pregnancies to Galway – would simply further reduce the skill set of the clinical staff, so is not a viable solution to the problems.
Furthermore, the staffing profile at Portiuncula reveals major issues of concern. While five consultant obstetricians for 1,400 births may appear satisfactory on paper, the new report reveals that one consultant is on long-term sick leave, one does not cover night duty, and at least one other works part-time only. This has led to a highly unsatisfactory reliance on locum consultants to cover out-of-hours deliveries and emergency Caesarean sections, especially at weekends.
On paper the box is ticked for consultant cover at the hospital. In practice, however, the locums may have flown into Ireland just for the weekend. Many will never have worked in the unit before, or indeed in Ireland, and may never have met any of the permanent staff in the hospital, including midwives (some of whom may themselves be temporary agency staff).
The locum will be unfamiliar with local work practices, management protocols and methods of communication among staff. Indeed, the report even identified poor mobile phone coverage making it difficult to contact the on-call consultant. At the end of the weekend, the locums often depart without appropriate handover to permanent consultant staff. This is not a sustainable model of maternity care.
A second major issue is governance. I have written many times about the value of the mastership model in obstetric care which places a doctor at the heart of management in the three Dublin maternity hospitals. For seven years, an elected consultant obstetrician has both authority and accountability. While the master works in a collegial manner with midwifery and lay management, he or she is in overall charge.
This is critical because, as experience tells us, a lay manager – no matter how well-intentioned – can never fully understand the intricacies of obstetric care, with the 24 hours a day, 365 days a year relentless nature of the delivery of safe care to women, where unexpected emergencies arise at any hour of the day or night, on any day of the week. The master has the ultimate responsibility for how the hospital operates and, crucially, has the authority to both allocate often limited resources and implement changes for the benefit of patient care.
By contrast at Portiuncula, the role of clinical director created after the Walker report was not given appropriate executive authority. The new report is clear: the holder has no regulatory or budgetary control. Requests for enhancement in services are routed through the hospital’s lay general manager and then through the line management structure in the HSE. This is simply toothless, and as the failure to improve services over the last seven years clearly shows, the system is failing women and their babies.
With the publication of the new Portiuncula report the HSE asserts its commitment to “implementing the 34 recommendations” made. But that commitment was made seven years ago: measures were put in place, but the problems persist. Concrete actions promised, such as the provision of additional theatre space for emergency Caesarean sections, have made no progress.
What the Portiuncula situation tells us clearly is that the smaller maternity units in Ireland are no longer able to deliver appropriate and safe levels of maternity and neonatal care. I absolutely concur with the latest report’s conclusion that there should be a review of the way maternity services are delivered across the country.
The safety of mothers and their babies must be put ahead of local interests where necessary. This will likely mean the closure of smaller units around the country and the transfer of care to larger maternity centres. This essential reform will require support – and not obstruction – from political leaders. The status quo is no longer a viable option.
Dr Peter Boylan is former master of the National Maternity Hospital and former chairman of the Institute of Obstetricians and Gynaecologists
