The National Director of Quality & Patient Safety at the Health Service Executive (HSE) has apologised “unequivocally” to four families who lost a child due to hospital childbirth medical negligence.
The apology by Dr Philip Crowley came prior to an RTE Prime Time television program – “Controversy at Midland General Hospital, Portlaoise – Fatal Failures” – which highlighted failings in care at the hospital that led to four babies dying in childbirth.
The program featured the story of Roisin and Mark Molloy from Tullamore, County Offaly, whose son Mark died shortly after being delivered on 24th January 2012. Medical staff at the hospital initially failed to inform the Molloys of the reason for their son´s death or conduct an investigation into the circumstances of his delivery.
It was only after a four-month battle against the hospital authorities that the HSE acknowledged there had been signs of life when Mark was born and an investigation was initiated. The investigation took over twenty months to complete – a “lamentable delay” according to Dr Crowley – during which time the Molloys were fed misinformation by HSE officials.
Among the things the Molloys were told was that childbirth deaths at the hospital were very rare; but when a subsequent independent clinical review reported “failures in the standard of care provided were casually linked to the foetal hypoxia damage that occurred [and the death of baby Mark]” it became clear that their son had been the victim of hospital childbirth medical negligence and the Midland Regional Hospital issued the Molloy´s with an apology.
By chance, Roisin Molloy heard a radio interview in which a Shauna Keyes was retelling the story of how she had lost her child at the Midland General Hospital in similar circumstances, and the two women got in touch with each other. The story found its way to the RTE Investigation Unit, who found two more examples of hospital childbirth medical negligence in which children had died, an investigation had been conducted, but the parents were never informed of the outcome.
Among the four instances of children dying shortly after birth, investigators discovered that, although sub-standard care had been identified during the investigation into Mark Molloy´s death, no measures had been taken to deal with the shortcomings, and that the same mistakes had been repeated in the deaths of the other three children.
It was also explained in the program that, in order to provide a “safe” level of service, the HSE recommends a ratio of one midwife for each twenty-eight women in the later stages of pregnancy. At the Midland Regional Hospital in Portlaoise there was a ratio of one midwife to seventy-five expectant mothers – a situation which resulted in “a lack of understanding of a deteriorating condition leading to a failure to seek timely medical assistance”.
RTE investigators were shown a copy of a letter written in 2006 by midwifery staff to the then Minister for Finance Brian Cowen and Minister for Health Mary Harney in which concern was expressed over staffing levels at the hospital. The letter said a “real fear” existed that a mother or baby would die before staffing issues were addressed and that the situation had been made clear to the management at the hospital, but no action had been taken.
Speaking on the Today radio program, the current Minister for Health James Reilly said that the hospital childbirth medical negligence at Portlaoise Hospital was “utterly unacceptable”, and that he planned to conduct a further investigation into the failings of care and the deception that the parents of the dead children had experienced.“I have asked the Chief Medical Officer to give me a report. It won’t take long and I will take action to make sure that this never happens again. I have put great emphasis on this.”