Publish baby death details to help others, pleads mum
The mother of baby Mark Molloy, who died in Portlaoise Hospital, said investigation reports into infant deaths in maternity hospitals should be automatically published if families give their permission.
Roisin Molloy and her husband Mark, of Killeigh, Co Offaly, pleaded with the HSE for two years to publish the report into their son's death at Portlaoise Hospital in January 2012.
"These reports should not be kept hidden away. They provide an opportunity for shared learning - not just in the hospital where the baby died, but in all maternity units across the country.
"The policy of containment, where reports are not released, is no longer tolerable.
"Baby Mark's report is now on the HSE website.
"It is what we repeatedly asked for and now it is open to others involved in maternity care to access it and learn lessons," said Mrs Molloy.
The report, completed two years ago and known as a systems analysis review, contains the CTG (cardiotocography) trace of baby Mark, which charts some of his final moments.
It highlights the failure of hospital staff to act on signs of foetal distress and fully assess all sections of the CTG reading.
This led to Mrs Molloy being inappropriately given the drug Syntocinon to speed up labour, even though this added further to the unborn baby's distress and a fall in oxygen.
There was also a delay in transferring Mrs Molloy to the operating theatre for delivery.
Mark died 22 minutes after his birth. His death was recorded as a stillbirth and his family faced a grinding struggle with the HSE to find out the real reason why their baby died at the end of a healthy pregnancy.
Baby Mark was one of five infants who died in similar circumstances in Portlaoise Hospital over a number of years . The high rate of constant night duty by some midwives also meant they were not fully supervised or doing courses to update their skills, the report found.
It was only after the Molloy family went public with other bereaved parents that the Health Information and Quality Authority (Hiqa) was asked to carry out an investigation into standards at the hospital, producing a damning report.
The HSE yesterday reiterated its unreserved apology to the Molloy family for the failings, distress and anguish caused to them.
It said these reviews as "tools for hospital management are, as such, not typically published".
The HSE said the 43 recommendations in the report had been implemented in Portlaoise and in other maternity units across the country. These include the appointment of more midwifery and specialist nursing staff for maternity services.
Other improvements in maternity services include staff having to undergo mandatory training in CTG tracing .
There has also been approval to appoint directors of midwifery in all 19 units to strengthen senior decision making.
Maternity units also now had to produce safety statements on a monthly basis from this month, it said.
These statements will have to reveal the number of critical incidents and other key information which should raise an alert about potential problems which are arising.
The HSE said that in the coming months clinical maternity networks would be established. This will be aimed at ensuring greater oversight of the smaller units by large hospitals.
The report into baby Mark's death stressed the need for proper bereavement systems to be put in place for a family whose baby dies. They include allowing parents to have a memento, such as a lock of hair or a footprint.
Mrs Molloy is now a member of a national strategy group drawing up a new policy for maternity services.