Over two years after it was completed, the HSE is to publish the official report into the death of baby Mark Molloy in Portlaoise hospital in January 2012.
The report is being released today at the request of his parents, Mark snr and Roisin, but the HSE has told them its publication does not set a precedent for the release of reports into other controversial patient deaths within the health service.
The death of baby Mark just 22 minutes after he was born in the maternity unit was the catalyst for a wider investigation into a series of baby deaths in Portlaoise that culminated in a damning report by the Health Information and Quality Authority earlier this year.
Molloys angered
The Molloys, angered by the refusal of the hospital and HSE management to properly investigate their son’s death, linked up with other bereaved parents to campaign for an independent investigation. The resulting Hiqa report found services at the hospital were unsafe.
The couple, who maintain other tragedies could have been averted if the lessons learned from their own son’s death had been properly and promptly learned, had called on the HSE to publish the report into the baby’s death so the information gained could be shared with other families.
The report, dated September 2013, identifies a number of serious failings in the care provided for Roisin Molloy and her newborn son.
There was a failure to recognise and act on the signs of foetal distress, and a failure to fully assess all sections of the CTG (measuring foetal heartbeat and contractions) resulting in the inappropriate prescription and administration of syntocinon, a drug used to accelerate delivery.
This also resulted in a delay in the decision to transfer Ms Molloy to theatre for an assisted delivery.
The report by two senior HSE officials also contains an apology to the Molloys and their families for the events that led to baby Mark’s death, on January 24th, 2012. It acknowledges their experience on that day was devastating for them and had a profound and lasting effect on their family.
The willingness of the couple to share their experience was invaluable in allowing the investigation to learn from this and make recommendations to improve systems in the hospital, according to the report.
The HSE promised to ensure the recommendations were implemented “as a matter of urgency”.
The report makes 43 recommendations for improving services, including a review of midwifery staffing levels and mandatory training in CTG scans for staff.
Facilities for foetal blood sampling should be provided at the hospital as a matter of priority, it says.
Provision of mementos
Guidelines should be developed in relation to the provision of mementos to bereaved parents, setting out the process to be followed when taking a lock of a baby’s hair or hand and foot prints following a baby’s death.
“The guidelines must state that the consent of the parents must be sought before taking mementos.”
Ms Molloy was admitted with labour pains at 5.05am on the day of her son’s death. Her scan was “non-reassuring” between 6.33am and 7.15am.
Prof John Morrison, a consultant obstetrician whose review of the case forms part of the final report, found baby Mark should have been delivered by 6.50am, in the absence of the availability of foetal blood sampling.
He described the decision to administer syntocinon at 8.15am as “unsafe and incorrect”.
Ms Molloy was seen by a consultant obstetrician at 8.39am and transferred to theatre, where baby Mark was delivered at 9.31am, developmentally healthy but short of oxygen. He was pronounced dead at 9.53am.
