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P20 Analysis of irish inquiry reports relating to pregnancy loss services (2005–2018)
  1. A Helps1,2,3,
  2. L O’Byrne1,
  3. S Leitao2,
  4. K O’Donoghue1,3
  1. 1Pregnancy Loss Research Group, University College Cork, Cork, Ireland
  2. 2National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
  3. 3The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland


Background External inquiries related to maternity services are sometimes carried out after negative media reporting of adverse events that have occurred. External inquiries aim to identify issues in the maternity care provided to pregnant women and to make recommendations to improve the standard of care; however, these recommendations are not always implemented. Published literature comparing external reports and assessing their impact on maternity services is limited. Hence, this is the focus of this study.

Methods Ten publically-available national health-service-commissioned inquiry reports published between 2005–2018 relating to perinatal deaths and pregnancy loss services, were identified from national inquiries into the maternity services in Ireland. These were assessed by 2 clinicians, separately, to compare and examine the content and recommendations made in each report.

Quantitative and qualitative data was collected using a specifically designed review tool (based on the Health Service Executive’s (HSE) Systems Analysis Review Report Checklist (SARRC)). The findings and recommendations from each report were studied by descriptive thematic analysis outlining emerging themes and issues.

Results The length of the reports ranged from 11–210 pages (average 86). A definitive purpose for the inquiry was stated in 6/10 reports. Half of the reports explained the inquiry methodology used (including reference to review tools).

The inquiry team was named and multi-disciplinary (MDT) in five reports (4–14 people); four reports described each person’s role, but not their responsibilities. It was clearly stated that affected families were involved in four inquiries and relevant clinical staff in four. The inquiry team commented on good aspects of care provided by clinical staff in only four reports.

In the recommendations four main domains were identified: management of information; pregnancy loss care; maternity services governance; workforce staffing and training. The SMART principle (i.e. specific, measurable, achievable, realistic or time-bound) was not consistently applied to the recommendations in any report, thereby reducing the chance of implementation.

Conclusion This was the first structured review of pregnancy-loss national inquiry reports, highlighting some of the main issues arising from them. The methodology used during the inquiry process was clearly described in only half of reports. Clearly standardising inquiry processes and highlighting all relevant issues is essential. For this purpose, structured national report checklists can be a useful resource. Additionally, a selected external expert MDT, clinical staff and families should always be involved in the inquiry process. Recommendations made within inquiry reports, can have a profound impact on maternity services if implemented appropriately. This will be explored further in an analysis of all implemented recommendations.

  • maternity care
  • pregnancy loss
  • national inquiry report review

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