Failures in maternity care at Portiuncula University Hospital led to the death of three babies and the serious injury of three more, a review has found.
The report, which was commissioned in January 2015, examined the delivery and neonatal care of 18 babies at the Galway hospital and found serious failings in care in half of those cases.
Of the 18 births examined by the review team, six involved either still-births or the death of the baby shortly after delivery. There were failures in care in four of these cases and “key casual factors” in three, which if handled differently would have likely led to a different outcome.
Of the babies who survived, six suffered injury including life-long disability. One suffered Hypoxic Ischaemic Encephalopathy (HIE) which can result in brain damage. Another had a skull fracture, asphyxia and has been diagnosed with epilepsy.
In three of these cases better hospital care would have led to improved outcomes, the report said.
The main failings identified by the review were a lack of available senior staff, especially on evenings and weekends, a lack of training in midwifery and poor communication with staff.
On several occasions, particularly out of hours and at weekends, no obstetric consultant or clinical midwifery manner was available to assist in the birth.
On another occasion, over a holiday weekend, there was an incorrect decision to defer an assessment of the foetus.
During the period under review, 2008 to 2014, two directors of nursing and one assistant director of nursing did not have midwifery qualifications. Drugs to aid in labour were also improperly administered.
There was a failure to disclosure information to families about their babies.
“They were absolutely not open to disclosure practices, there was no willingness to explain to us in an honest and open way what had happened,” said Warren Reilly who lost two daughters at the hospital in 2008 and 2010.
“We were told this is an unfortunate incidence, these things simply don’t happen, this is the only case here. We were led to believe it was just bad luck.”
An internal review was carried out into the death of Mr Reilly’s second daughter in 2011 but he and his wife did not find out about it until 2015.
The report also found insensitive or inappropriate interactions with bereaved families.
One a family received a call asking about their baby’s welfare after the baby had died. Another family received the same request on the day of their baby’s funeral.
In some cases there were inappropriate arrangements for follow-up appointments including where parents who lost a baby had to wait for over an hour in a waiting room surrounded by expectant women.
The HSE and Portiuncula yesterday apologised for the failings and said the report’s recommendations are being implemented in consultation with the affected families. They also apologised for the delay of the report which was originally due in mid-2015.
Dr Pat Nash of Saolta, the hospital’s parent group, said 90 per cent of the report’s recommendations have been implemented since 2014.
