Damning health report sparks maternity unit alert
Kenny vows to overhaul the system as devastated families finally learn grim truth
Published 01/03/2014 | 02:30
A DAMNING report into the deaths of four babies has raised safety fears for maternity units across the country.
Major lapses at Portlaoise Hospital may be replicated in other facilities where thousands of babies are born every year, it has emerged.
Hospitals that deliver less than 2,000 infants a year are now to be linked with larger maternity services in a bid to share expertise and prevent further tragedies. The change follows revelations of "appalling" and shocking care at the maternity unit in Portlaoise Hospital where the babies died from lack of oxygen.
Now some 12 similarly sized units, which deliver 2,000 babies or fewer annually, are to be reviewed and linked up with larger maternity services in their region.
The move puts a question mark over the future of some of the units as the birth rate falls. The review follows a report by chief medical officer Dr Tony Holohan, which revealed "appalling" levels of care given to parents and babies who may have needlessly died in the maternity unit in Portlaoise.
An emotional Health Minister James Reilly said the Portlaoise unit was not safe and that he had installed senior staff from the Coombe Hospital in Dublin to take over its running.
He said: "I am asking that on foot of the implications of this report the HSE also look at other similar sized maternity services around the country and consider their incorporation into managed clinical networks within their relevant hospital group."
He also revealed a fifth baby death in Portlaoise was now being investigated after a number of families came forward seeking answers after losing their child.
The four families whose babies died in similar circumstances in Portlaoise between 2006 and 2010 broke down in tears after the minister referred the scandal to the Health Information and Quality Authority (HIQA) for a full investigation.
In his opening address at Fine Gael's Ard Fheis in Dublin, Taoiseach Enda Kenny vowed the health system would no longer be one that ignored concerns and forces families to "fight for truth". He said the Department of Health report into the babies' deaths made for "grim reading" before paying tribute to the resolve shown by families of the deceased.
Mark and Roisin Molloy, who led the campaign for an inquiry after losing their son Mark two years ago, said: "We are relieved. It has taken a long time but at last somebody is listening to us."
Internal reviews found babies died in similar circumstances from the effects of lack of oxygen after a failure to recognise or identify foetal distress during their mother's labour. The women were also given the drug syntocinon to speed up labour leading to even more oxygen deprivation.
Dr Holohan's report, which followed an RTE 'Prime Time' programme, revealed:
* Families and patients were treated in a poor and at times appalling manner with limited respect, kindness, courtesy and consideration.
* Information about the baby deaths should have been given to families but was withheld for no justifiable reason.
* The deaths may have been prevented if the hospital had acted on the lessons from previous adverse events.
* Many organisations, including the HSE, had partial or a "jigsaw" of information about the safety risks in Portlaoise but failed to share it. The external support and oversight from the HSE was not strong or proactive enough.
Mothers who lost babies found themselves with women who gave birth, appropriately sized coffins were not always made available, infants were transported in the boots of taxis for post-mortems and the hospital suffered from inadequate facilities and equipment.
It found that there was a very high overall number of obstetric incidents in Portlaoise in 2007 which were reported by midwives in particular who were concerned about staffing levels.
However, the minister insisted that staffing levels at the hospital did not explain the lapses. He said: "In relation to midwifery staffing, I am requesting the HSE to conduct an examination of midwifery workforce planning both in Portlaoise maternity unit and in general across the country."
The clinical director of the Portlaoise hospital apologised for failures in maternity services at the hospital. Dr John Connaughton said: "The staff at Portlaoise Hospital apologise unreservedly to all families who experienced care below the expected standard at the maternity services in Portlaoise Hospital over the past number of years.
"For those families who suffered loss as a result of care failings the hospital expresses its deepest regret and sympathy."
He described the failure to communicate with the families when they most needed honesty, compassion and kindness, as unacceptable. It was equally unacceptable investigations were not carried out in a timely manner, he added.
"At the time the babies died investigations commenced after that. Those investigations did not proceed at the rate that they should have, that is unacceptable and that cannot happen again."
Asked if he felt responsible for governance and management issues at Portlaoise Hospital, he replied: "I have been clinical director since 2009. A lot of work has gone into the governance structure in this hospital over the last two years. The new arrangements are in place and maternity services will be much safer."
Michael Knowles, who is currently general manager in Naas Hospital, has taken up the same position at the Portlaoise maternity unit. Angela Dunne, currently the assistant director of the Coombe Hospital, is the new director of midwifery.
Portlaoise Hospital is operating a helpline from 9am until 5pm. The contact number is 057 8696076.