Irish Inquiry Reports Relating to Perinatal Deaths and Pregnancy Loss Services

Area of Science:

• Healthcare quality improvement
• Patient safety research
• Maternal health services

Background:

• External inquiries are conducted after adverse healthcare events, especially in maternity care, to identify systemic issues and enhance care standards.
• Review of publically-available national inquiry reports published between 2005-2018 concerning pregnancy loss services.

Purpose of the Study:

• To analyze the content and recommendations of national inquiry reports related to pregnancy loss services.
• To assess the involvement of affected families and clinical staff in these inquiries.
• To identify common themes and gaps in the inquiry and reporting process.

Main Methods:

• Systematic review of ten publically-available national inquiry reports (2005-2018) on pregnancy loss services.
• Independent review of report content and recommendations by two clinicians.
• Analysis of recommendation themes, stakeholder involvement, and feedback mechanisms.

Main Results:

• A total of 258 recommendations were identified across 9 reports.
• Recommendations frequently focused on increasing workforce staffing/training, strengthening clinical governance, enhancing adverse incident management, and improving data collection.
• Involvement of affected families was explicitly stated in 50% of inquiries, and affected clinical staff in 40%.

Conclusions:

• A significant proportion of inquiries recommended improvements in staffing, governance, incident management, and data collection.
• Limited feedback was sought from key stakeholders prior to report publication in most inquiries.
• A standardized, collaborative inquiry process involving all affected parties and stakeholders is essential for effective learning and implementation of recommendations.