Abstract

External inquiries are carried out following significant events in maternity services, to examine the care provided and make recommendations for improvements where necessary. Clinical governance ensures that organisations promote high-quality care and are accountable for the care they provide, thus contributing to its improvement. We examined how Irish perinatal bereavement services and the management of perinatal deaths were affected by developments in maternity services governance, as described in ten Irish enquiry reports published over 14 years (2005–18). Seven main themes were identified: workforce, leadership, management of risk, work environment, hospital oversight, national documents, data collection. Eight reports noted shortcomings in staffing levels, with a workforce that was under-resourced, and at times carried excessive workloads. The absence of 24/7 midwifery-shift leaders in maternity units resulted in problems with care, at times, not being escalated appropriately. The absence of a widely-owned strategic plan for the management of the maternity services was mentioned in the reports from 2013. Greater focus on hospital oversight, implementation of national documents and reliable data collection is required. To be effective and initiate positive changes in clinical services, documents such as incident reviews, national strategies and national reports including inquiries, need to include realistic recommendations with clear timelines and responsibilities for implementation.