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Wednesday 1 October 2014

Portlaoise express "deepest regret and sympathy" over baby deaths

Report highlights families of four babies who died in hospital suffered poor and appalling treatment

Ed Carty

Published 28/02/2014 | 13:24

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Mark and Roisin Molloy during the launch of a report, into the deaths of four babies at the Midlands Regional Hospital Portlaoise. Photo: Niall Carson/PA Wire
Roisin Molloy (left) during the launch of a report into the deaths of four babies at the Midlands Regional Hospital Portlaoise in Dublin, as her son died 22 minutes after birth at the hospital on January 24 2012. Photo: Niall Carson/PA Wire
Health Minister James Reilly
Health Minister James Reilly

The Clinical Director of the Midlands Regional Hospital in Portlaoise has said that staff "apologise unreservedly" for failures in the maternity services that led to the deaths of four babies

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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," Dr Connaughton added.

The families of four babies who died at Portlaoise in similar circumstances over several years suffered poor and appalling treatment by health chiefs.

A report into the deaths at the Midlands Regional Hospital Portlaoise found their mothers and fathers got limited respect, kindness, courtesy and consideration after raising concerns about the deaths.

Chief medical officer Dr Tony Holohan reviewed the deaths, which took place from 2006, and found information that should have been given to families was withheld for no justifiable reason.

Families have been pressing for an independent inquiry, including Mark and Roisin Molloy whose son Mark died 22 minutes after birth at the hospital on January 24 2012.

All four babies died either during labour or within seven days of birth and a feature common to all of their deaths was anoxia, oxygen starvation to the brain.

It is believed foetal distress was not properly recognised or acted on while mothers were in labour.

Commenting on the report Roisin and Mark, said they were not  shocked at the extent of the failures it revealed.

“When we met with the Minister we brought all this to his attention. There is nothing new in it .

“We identified that baby deaths were not being fully reported. The newness now is that somebody has listened to us and recognised that our babies deaths mattered. The HSE knew all of this.”

Mrs Molloy said if she had more children she would not go back to the maternity unit even if there is new management.

“Our history is too traumatic,” she added.

Health Minister Dr James Reilly praised the families involved for persevering with demands for answers from the hospital - ultimately some of them went public.

"I very much admire their strength and tenacity and I respect their commitment to ensure that their babies' stories have been heard," he said.

"I can assure them that the actions they have taken resulting in this report will make a significant difference to how we manage our maternity services in future."

Dr Reilly said the chief medical officer's report identified clear failures, at local and national level, in the management of risk and patient safety in the Portlaoise maternity unit.

It found the unit unsafe under its current governance and a transition team has been put in control of maternity services.

"I am conscious that recent events in Portlaoise have damaged public confidence in the hospital," Dr Reilly said.

"However, I am satisfied that Portlaoise Hospital will, through the establishment of a managed clinical network with the Coombe, be supported to ensure the provision of improved, safer, patient-centred maternity services."

The watchdog, the Health Information and Quality Authority (Hiqa) has been asked to investigate Portlaoise maternity services and report by the end of the year.

Ahead of that inquiry, the chief medical officer also found poor outcomes that could likely have been prevented were identified and known by the hospital but not adequately and satisfactorily acted upon.

The maternity unit lacks many of the important criteria required to deliver, on a stand-alone basis, a safe and sustainable maternity service.

External support and oversight from HSE should have been stronger and more proactive, given the issues identified in 2007, the report found.

Two of the families met Dr Reilly and Dr Holohan in the wake of an RTE Prime Time programme which exposed the families' quest for answers and treatment by hospital chiefs.

The Molloys, from Co Offaly, who had to seek to have their son's death register changed from stillborn to newborn, sought explanations on their son's death from the HSE for two years.

In a statement the Health Service Executive (HSE) reiterated its apology to families.

"The HSE and the hospital accept that there were significant shortcomings in the cases referred to in the report, particularly in relation to the level and quality of care afforded to the patients in question and to the sub-standard communications with their families," it said.

"The HSE and the hospital have earlier apologised unequivocally to the families for these failings.

"The HSE and the Portlaoise Hospital wishes to, once again, repeat this unreserved apology for the failings in the care outcomes experienced by the families concerned, for failing to ensure that prompt incident investigations were undertaken and for the manner in which Portlaoise maternity unit responded to the families when they most needed compassion, candour and courtesy shown to them."

Director general of the HSE, Tony O'Brien, has written to staff in the agency highlighting the importance of honest communications with patients and families.

He warned that failure to do so "erodes public confidence in health services, lets down the public and lets down the service as a whole".

Dr Reilly disclosed one medic at Portlaoise is subject to investigation by their relevant professional, medical body.

The report made damning findings in relation to the deaths of Katelyn Keenan, Joshua Keyes-Cornally, Mark Molloy and Nathan Molyneaux at Portlaoise.

It found 1,983 births in Portlaoise in 2013 and 17,025 since 2006 but major discrepancies across the health system on how perinatal deaths and still births are recorded and called for a new way of recording.

It said the current system was disparate and leads to confusion and duplication and adds to the workload for maternity units and is an additional strain on scarce health service resources.

Dr Holohan's report said that data from Portlaoise could have flagged suspicions of problems with care at the maternity unit.

Records showed birth rates rose very quickly over a short period.

They showed a number of what are defined as never events - medical errors which should not have occurred - while there were also a number of other serious adverse events and a rise in notifications of adverse incidents.

The figures showed a significant increase in transfers out of Portlaoise for both maternity and paediatric care and a higher than expected rate of obstetric claims.

Dr Holohan's report found: "While there was awareness that the service was under pressure, there does not appear to be any evidence that monitoring of how this might have been impacting on patient care was taking place."

He found a culture of insensitivity among staff in Portlaoise in the maternity and paediatric units.

Backs were being turned, honest accounts were not given, unprofessional behaviour and language was frequent and insensitivity and a lack of empathy were common, the report found.

It said younger patients were spoken to through their mothers rather than directly, leaving them feeling judged by staff.

More than one member of the senior clinical staff at the hospital invited families to sue.

On top of those inadequacies grieving families were further distressed by the manner of the care in the immediate aftermath of perinatal deaths.

"These accounts were powerful, clear and consistent," Dr Holohan's report found.

As well as inadequate facilities and equipment adding to the trauma, mothers were not necessarily moved for other patients with healthy new borns; practices for handling, holding, dressing, bathing and photographing their dead babies were at best variable; and appropriately sized coffins were not always available.

The report said one especially-distressing finding was dead babies being taken in the boot of a taxi to Tullamore hospital for a post mortem.

Dr Holohan said families refused information and answers blamed themselves for something they had no responsibility for.

Mark Molloy, who battled for two years for information on his son's death, said it was a day of mixed emotions.

"For us, when everything is implemented, when we have statistics we can rely on, safe maternity units, no-one is going to say to us, 'here, well done, have your little boy back'," he said.

Dr Reilly said families had been fobbed off by medics in Portlaoise. "I'm at a loss as to explain why they would be treated like this," he said.

He has also called for a change in the rules around coroner's courts, stating that the death of any baby once labour has commenced should be reviewed in an inquest.

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