SENIOR doctors at the centre of the miscarriage scandal in which two unborn children died are still not properly trained.
he frightening disclosure for thousands of mothers-to-be is made in the first major report into the blunders.
The report was in response to revelations by the Irish Independent that mothers were wrongly informed their child was dead in the womb.
But nobody is held accountable, and no names of those involved have been revealed by the 10-month inquiry.
Instead it blames inadequate training and over-reliance on ultrasound for 24 women being wrongly told their unborn baby was dead.
The HSE has made some changes since the miscarriage scandal was revealed last year. But while vital training in reading early pregnancy scans has begun, the HSE cannot say when all medics -- including consultants and registrars -- will be trained.
For example, the first group will not be trained until Christmas. This means it could potentially be years before all staff are up to the new standards.
Last night a mother, who saved her child's life by getting a second opinion after being told her baby was dead in the womb, said she would still have worries about the system.
Martha O'Neill Brennan said: "I can't see a big change if I presented to the hospital today with the same symptoms I had four-and-a-half years ago. I would be treated in the same way."
Most of the medical professionals involved were highly qualified consultants and registrars who failed to spot signs of life in an ultrasound. The report suggests that while they were highly qualified, they did not have the training required for the acute level of detection needed during early pregnancy.
The key findings include:
- Poor qualifications among staff who mistakenly told mothers their unborn children were dead.
- Problems with scanning equipment, and the reluctance to offer women a second ultrasound scan.
- Errors at 16 of the 19 maternity wards in the country.
But the report failed to name the people implicated or identify the hospitals involved. And the recommendations stopped short of making second scans mandatory in cases of suspected miscarriage.
This is despite the fact that in all 24 cases identified in the report the women asked for additional scans after being told they miscarried, and in this way were able to find that their unborn child was still alive.
Professor William Ledger, who headed up the review, said: "We want to change the culture so that women don't have to demand a second scan. We want a situation where it is discussed and offered."
Prof Ledger said making a second scan compulsory could jeopardise the safety of the women involved: "You cannot be sure. There is no benefit in reviewing the records of every woman who has a miscarriage."
He also said the problems were "systemic" rather than confined to one doctor or hospital. "The biggest problem has been a lack of training and credentialing," he said.
Hundreds of medical staff will now have to take part in new training.
Health Minister James Reilly last night said all ultrasound equipment over five years old would be replaced within the next few weeks.
The misdiagnosis scandal emerged after the Irish Independent last year revealed the case of Melissa Redmond, a mother from Donabate in north Dublin.
Following a scan at Our Lady of Lourdes Hospital in Drogheda, she was told that she had miscarried. But the mistaken diagnosis was spotted in time and her baby Michael is now one year old.