Damning report highlights litany of failures at maternity hospital
There were "significant failings" in the care provided to four babies who died in Portiuncula University Hospital, according to a damning review of 18 maternity cases over which concerns were raised in a seven-year period.
Of the 18 cases, six babies died and in 10 cases there were there "serious errors of management that would probably have made a difference to the outcome for babies", the report states.
In all 18 cases of babies who either died or were born with a disability, which occurred between 2008 and 2014, the review team identified contributory factors and/or incidental findings.
The shocking litany of failures and errors is outlined in a long-awaited report of an independent review of maternity services at the hospital, which was led by Prof James Walker, Professor of Obstetrics in the University of Leeds.
As the findings were finally published, the hospital leadership apologised to the families involved and outlined the steps that have been taken to strengthen governance, patient safety and communications at the Ballinasloe, Co Galway, hospital.
A total of 154 recommendations were made based on the individual cases and there were further recommendations made in the final report.
Key issues highlighted in the report include delays in escalation of concerns to more senior decision-makers, not enough medical and nursing staff, poor CTG (trace) interpretation and concerns relating to the administration of oxytocin, a drug given to mothers to speed up labour. The report also raised concerns about the way many families were communicated with, either during or after their time in hospital, and highlighted historical issues relating to governance structures in place between the hospital and the group at the time.
One family was contacted by the hospital to inquire about their baby although the infant had died, the report noted. Another family received a call about their baby as the child was being buried.
The review also found there was a lack of midwives and consultants.
Two directors of nursing and one assistant director of nursing did not have midwifery qualifications and there was also a failure to openly disclose mistakes to parents.
In his apology, Dr Pat Nash, group chief clinical director of the Saolta University Health Care Group, said it had been "an extremely traumatic process" for the families, which had been "compounded by the length of time this complex review process took to complete".
Dr Nash said they wanted to assure women that an improvement plan was in place to make the service safer.
Loughrea couple Warren and Lorraine Reilly lost two daughters born in the hospital, Asha and Amber, in 2008 and 2010.
Mr Reilly said there were no surprises in the report as he knew the types of issues within the hospital.
He said there was a "lack of compassion" from some in dealing with families, but the most worrying issue was that a report was conducted on Amber in 2011 and there was a decision to not make him or his wife aware of it.
"We, at that time, had been led to believe by the hospital that everything was as expected and that it couldn't have been avoided and was just one of those things," Mr Reilly said.
"We were never led to believe there was any negligence.
"It's been an absolutely harrowing and traumatic experience, to be honest, it's taken a toll on both of us physically and mentally but we're glad we've stuck with the process and held the HSE and Saolta to account for the failings in the past."