MEDICAL NEGLIGENCE PATIENT SAFETY ITEM 2.1 (a) and (b)
MEDICAL NEGLIGENCE PATIENT SAFETY ITEM 2.1 (a) and (b)
PATIENT SAFETY ACT 2023
John Whelan Solicitor with specialist expertise in Medical Negligence and Patient Safety gives an example of a Notifiable Incident as envisaged by Item 2.1 of the Act.
There are 13 notifiable incidents set out in the Act but other notifiable incidents may be introduced by Ministerial regulation under Section 8 of the Act.
Item 2.1 (a) and (b)
This is an example of a situation where therapeutic hypothermia was considered but ultimately contraindicated due to the severity of the baby’s condition which is a notifiable incident as envisaged by items 2.1 (a) and (b) of the 2023 Patient Safety Act.
Case Example: Severe Birth Asphyxia with Multiorgan Failure
A full-term baby was born after a prolonged and complicated labour. Due to issues with the umbilical cord, the baby suffered from severe birth asphyxia (lack of oxygen to the brain). Upon delivery, the baby had a very low Apgar score, showing signs of severe hypoxia, including poor muscle tone, irregular heart rate, and minimal respiratory effort. The baby required immediate resuscitation.
Once stabilised, the baby was diagnosed with hypoxic ischemic encephalopathy (HIE), a condition where the brain is deprived of oxygen. In such cases, therapeutic hypothermia, or cooling therapy, is often considered to reduce brain damage by slowing down metabolic processes. The treating neonatologist considered initiating therapeutic hypothermia.
However, upon further examination, it was found that the baby’s condition was far more severe than initially thought. The baby had signs of multiorgan failure, including critical heart dysfunction (severe bradycardia), liver damage, and very poor blood flow. The baby’s blood pressure was dangerously low, and the baby required significant support to maintain vital functions.
Given the severity of the baby’s condition, the treating doctor determined that therapeutic hypothermia, which can further depress heart function and lower blood pressure, was contraindicated. Cooling therapy could worsen the already unstable cardiovascular state and increase the risk of cardiac arrest. The medical team decided to focus on other intensive interventions to stabilise the baby’s organs instead of proceeding with therapeutic hypothermia.
In this case, despite therapeutic hypothermia being a standard treatment for babies with HIE, the doctor judged that the therapy posed too high a risk for the baby due to severe systemic instability and multiple organ failure.
For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/