SOME members of the midwifery staff at Portlaoise Hospital worked continually on night duty, an internal report into the death of a baby found.
The report, commissioned after the death of baby Mark Molloy in 2012, found this meant that opportunities for their ongoing supervision and assessment were limited.
Senior staff had recognised that the practice of some midwifery staff working continuous nightshifts was an issue that had already been identified by management.
The unpublished report, which was finalised in September, said it should be a mandatory requirement that all midwifery staff allocated to the maternity department in Portlaise be rostered to day duty for a defined period of time.
It was recommended all midwifery staff should work a minimum of three months of day shifts a year. The report also recommended that attendance at workshops on CTG monitoring to assess the baby's heart rate be part of the mandatory training schedule for all medical and midwife staff.
It said the frequency of attendance should be based on training needs, but attendance at the workshop must be a minimum of three times a year.
An anonymised copy of baby Mark's CTG should be included as a learning tool in the workshops that take place within the maternity department.
The report revealed that all hospitals were told to set up a clinical governance committee in 2010. It would mean that healthcare teams would be accountable for the quality, safety and satisfaction of patients in the care they deliver.
They should meet regularly to review incidents and risks. However, the inquiry team found they only met on two occasions in 2010 and "no further meetings" took place.
The confidential investigation emerged in the wake of last week's report of the chief medical officer Dr Tony Holohan, who found the Portlaoise maternity unit to be unsafe.