Senior consultants at the maternity unit in Cavan General Hospital raised serious concerns over patient safety at the hospital months before the HSE launched an investigation into baby deaths last year, the Sunday Independent can reveal.
The warnings come as it emerged the tragic deaths of four babies at the hospital are now being investigated, including a baby who died during a Caesarean section delivery last week.
Two others baby deaths were also reviewed internally by the hospital, but these cases did not warrant further investigation.
There have also been at least four other "near death" incidents which were reviewed by the hospital but did not require further investigation, the Sunday Independent has learned.
Despite the number of investigations into baby deaths at the hospital, Health Minister Leo Varadkar has insisted there is no need for the Health Information and Quality Authority (Hiqa) to investigate the maternity unit.
However, internal hospital correspondence - seen by the Sunday Independent - shows increasing fears over patient safety among the maternity unit's senior consultants.
All four of the unit's consultants raised concerns with management about an expectant mother who was forced to wait three hours for an operation due to a lack of staff.
In a letter dated March 26, 2014, the doctors said they previously raised the issue with management but did not get an "adequate response" and were now demanding "immediate action".
"It was agreeable by all consultant obstetricians that the care of this patient was inadequate and this patient shouldn't have been waiting all these hours to have a third- degree perineal tear repaired in theatre as this carried increased risk of infection," the letter stated.
"This case highlights the need for a dedicated theatre for obstetrics and gynaecological emergencies available all the time. Due to the seriousness of this problem, we would like you to take immediate action regarding the above mentioned problem," it added.
A month later the HSE launched a "full and thorough investigation" into the tragic death of a baby who died during a Caesarean section operation.
Dr Salah Aziz, who was involved in that delivery, was put on paid administrative leave pending an external investigation before any findings were made in relation to him.
It is understood Dr Aziz made claims about been bullied before he was suspended, an allegation that is recorded in the minutes of a meeting he held with hospital management.
Less than a month later, another baby died at the hospital. The HSE began another investigation. Dr Aziz was not involved in this delivery.
In 2011, Dr Aziz, who is still suspended and facing a Medical Council fitness-to-practise investigation, wrote to hospital management warning about surgery rosters for Caesarean sections.
Dr Aziz claimed there was an "inequality" of access to the operating theatre and this arrangement was "not workable and dangerous". He also claimed management was "interfering" in clinical practice. The HSE denies this was the case.
A year later, Fiona Watters lost her baby Jamie Flynn after giving birth in the hospital and Dr Aziz, who delivered the baby, was placed under investigation by the HSE.
Dr Aziz told the inquest into Jamie Flynn's death that he was forced to delay an emergency C-section on Ms Watters as there were no nursing staff available to man the operating theatre and instead tried to deliver the baby naturally.
A coroner's court ruled the baby died by misadventure, citing the administration of labour-inducing drug, oxytocin. The coroner recommended the hospital review its out-of-hours staffing arrangements.
Dr Aziz successfully took a High Court action against the HSE blocking it from publishing its findings on the Jamie Flynn case.
The HSE has since launched a second investigation into the same incident.
The new disclosures about the maternity unit in Cavan will add to pressure to begin a full open investigation into patient care at the hospital.
Standards at the country's regional maternity units have come under heavy scrutiny in the fall-out of a damning report on maternity services in the Midlands Regional Hospital in Portlaoise by the health watchdog, Hiqa.
Concerns have been flagged at Portiuncula, where 12 births are being independently investigated, and most recently at Cavan General Hospital.
Dr Peter Boylan, consultant obstetrician and gynaecologist at the National Maternity Hospital, warned against inappropriate political interference if small maternity units have to be shut down.
In today's Sunday Independent, he writes: "Rationalisation of services (that means closure of small units), if that is what the maternity strategy recommends, must not be subjected to inappropriate political interference."
He said patients need to be "embraced as partners in the provision of health care and we midwives and doctors, as professionals, need to be able to have a relationship of trust with our patients so that when adverse events occur, as they will, we can be frank with them about what went wrong."
He also suggested holding senior health management to account on patient safety "might bear further investigation."
"How far up the organisation the trail might lead would be of great interest to those at the front line who carry the can when it comes to adverse outcomes flagged by clinical staff in advance."
Meanwhile, a clinical review of 28 baby deaths and traumas has recommended that a number of cases, thought to be up to eight, should go to a full-scale investigation, according to informed sources.
The cases were reported to a helpline by parents and families in the aftermath of the RTE documentary that first highlighted concerns about the deaths of babies in Portlaoise last year.
Most of the cases that will be investigated relate to the maternity unit at the Midlands Regional Hospital Portlaoise.
The focus shifted to Cavan General Hospital last week following the death of a baby in the maternity unit, as the health minister met with parents to hear their stories of trauma and loss arising from their treatment at Portlaoise Hospital.
The HSE insisted patient care is audited by senior clinicians, senior nursing staff and management on a weekly basis and all recommendations are implemented.
"Cavan General Hospital's annual figures for mortality and significant illness among babies delivered have consistently compared very well to figures for other hospitals nationally and internationally," a spokesperson said.
Last year was undoubtedly the most difficult for Patient Focus. We spent 2014 speaking to the broken-hearted families of babies who died or were injured in Irish maternity units. Last week, after the publication of the Hiqa report into Portlaoise, the Minister for Health, Leo Varadkar, wanted to meet them. He wanted to hear what they had to say.