Hospital staff failed to recognise signs of foetal distress in baby Mark Molloy who died at 22 minutes old - report
THE HSE has apologised to the parents of a baby who died at a Portlaoise hospital, as “significant failings” were identified in a review of the circumstances of his death.
Roisin and Mark Molloy’s baby son died at the Midland Regional Hospita in 2012, just 22 minutes after he was born. His death was incorrectly recorded as a stillbirth.
The Molloys claimed his death was caused by negligence and breach of duty, and had called for an inquiry.
Now the HSE has published a report which has identified failings during the care, management and treatment delivered to Mrs Molloy and her infant son on January 24, 2012.
“The Midland Regional Hospital Portlaoise and the Health Service Executive would like to sincerely apologise to Mr. and Mrs. Molloy and their family for the events that occurred on the 24th January 2012 related to Mrs. Molloy’s labour and delivery and for the death of their infant son Mark.”
“The Midlands Regional Hospital Portlaoise and the HSE acknowledges that Mr. and Mrs. Molloy’s experience on the 24th January was devastating for them and that it has had a profound and lasting effect on their family.”
“Many of the staff interviewed as part of this investigation expressed their sympathy for what had occurred related to the events of Baby Mark’s delivery and death."
The HSE also said the willingness of Mr and Mrs. Molloy to share their experience was invaluable in allowing this investigation to learn from their experience and in helping to make recommendations to improve the systems and processes in place at the Midland Regional Hospital Portlaoise related to the delivery of Maternity Services.
"The HSE and the hospital have confirmed that it is committed to ensuring that the recommendations identified by this investigation report are implemented as a matter of urgency,” the report said.
Today’s HSE report identified two ‘care delivery issues’ related to the case.
It admitted there was a failure to recognise and act on the signs of foetal distress. It also said there was a failure to fully assess all sections of the CTG (cardiotocography) resulting in a) the inappropriate prescribing and administration of Syntocinon and b) a delay in the decision to transfer Mrs. Molloy to the Theatre Department for an assisted delivery.
The HSE's report also said there was evidence that the baby was showing signs of foetal distress from 6.30am and that at that time assistance should have been sought from the obstetric gynaecology clinical team on duty. However, these signs were not identified and acted upon.
"The investigation found that when Mrs Molloy was assessed by the Obstetric Gynaecology Registrar at 07.55 hours that all sections of the CTG trace were not inspected and assessed at that time and that therefore the earlier decelerations i.e. that had occurred between 06.33 hours and 07.15 hours and at 07.45 hours were not identified which led to the decision to inappropriately prescribe and administer Syntocinon."