A report on Portiuncula University Hospital has found serious failures in the delivery and neonatal care of half of the 18 babies whose cases were reviewed.
A third of the 18 reviewed cases involved still-births or the death of the infant not long after birth. Of these cases, four involved failures in care, and the failings were 'key causal factors' in three. This means that the outcome would have likely been different, had the case been managed differently.
As well, out of the children who survived, six were injured. For some, these injuries resulted in life-long disability. The report noted that better care would have led to different outcomes in three of these cases.
One infant suffered a skull fracture, asphyxia, and has been diagnosed with epilepsy. Another child experienced Hypoxic Ischaemic Encephalopathy (HIE), a type of brain damage.
As well, the report observed that had obstetric care been managed differently, outcomes would have been different in 10 out of the 18 total cases.
The report on the Galway hospital was commissioned in January 2015, according to the Irish Times. It was originally due in mid-2015, and the HSE has apologised for the delay.
Main failures in care were detailed in the report, including that senior staff were not always available, particularly during evenings and weekends. Poor communication with staff and lack of training in midwifery were also noted as main failings in the report.
On several occasions, oxytocin, a drug used to aid labour, was used incorrectly. According to the Irish Times, the report also found that prenatal signs of a possible problem with birth, such as abnormal foetal heartbeat, went unrecognised.
Insensitive or inappropriate interactions with families who had lost a child were mentioned, too. In one case, parents were called and asked about the health of their baby on the day of the infant's funeral.
The HSE and Portiuncula have both apologised for the failures in care, as well as the delay in the report's release.
According to the Irish Examiner, Minister for Health Simon Harris says that a team established by the HSE and Portiuncula Hospital will be consulting with the families involved.
Dr Pat Nash, group chief clinical director with Saolta University Health Care Group (the hospital's parent group), addressed the affected families:
"I want to take the opportunity to apologise again to the families for the failures in the care identified and also for the length of time that this review has taken."
Dr Nash said that 90 percent of the report's recommendations have been put in place since 2014. The report reviewed the period from 2008 to 2014.
The report's author, Professor James Walker, said that the report was not about assigning blame. Rather, he said that all staff and national agencies need to take action so these failings are not repeated.
