Dr Philip Crowley – the National Director of Quality & Patient Safety at the Health Service Executive – has apologised on behalf of the HSE to four families who lost a child due to hospital childbirth negligence at Portlaoise Hospital.
The apology by Dr Crowley was made shortly before an RTE Prime Time television program was scheduled to be broadcast, which highlighted tragic failings in the standard of care at the hospital which led to four perinatal deaths during, or shortly after, the delivery of the babies.
The program – “Fatal Failures” – primarily focused on the story of Roisin and Mark Molloy from Tullamore, County Offaly; whose son Mark died shortly after being delivered on 24th January 2012.
Roisin and Mark had to fight a four-month battle before the hospital acknowledged that their son was still breathing when he was delivered – a condition that is required before an inquest can be held into a fatality.
The hospital´s own investigation into Mark Molloy´s death extended over twenty months – a delay which Dr Crowley described as “lamentable”. He also acknowledged that the Molloys had been deliberately misinformed when they asked questions about the death of their son.
A subsequent independent clinical review into Mark´s death reported “failures in the standard of care provided were casually linked to the foetal hypoxia damage that occurred [and the death of baby Mark]” and made recommendations to prevent such tragedies in the future.
However, as the RTE Investigation Unit discovered, the hospital childbirth negligence continued, and was responsible for the death of three more children due to foetal hypoxia. Two of the deaths were investigated internally, but the parents of the dead children were never advised of the outcomes.
The RTE investigators found that none of the measures that had been recommended following Mark Molloy´s death had been put into practice, and that there was an extreme shortage of midwives to provide as “safe” level of service.
Indeed, whereas the HSE recommends a ratio of one midwife for each twenty-eight women in the later stages of pregnancy, the Portlaoise Hospital had one midwife for every seventy-five expectant mothers – leading to “a lack of understanding of a deteriorating condition resulting in a failure to seek timely medical assistance”.
RTE investigators were also shown a letter written in 2006 by the hospital staff to the then Minister for Health Mary Harney and Minister for Finance Brian Cowen. In the letter concern was expressed over staffing levels at the hospital – a situation had been made clear to the hospital management, but no action had been taken.
The letter concluded by saying there was a “real fear” in the midwifery department that a mother or baby would die before the staffing issues were resolved.
The current Minister for Health James Reilly was invited onto the Today radio show, where he was asked about the hospital childbirth negligence that had taken place at Portlaoise Hospital.
The Minister said that the situation was “utterly unacceptable”, and that he planned to conduct a further investigation into the failings of care at the hospital and the deception that the parents of the dead children had experienced.
“I have asked the Chief Medical Officer to give me a report”, he stated, “It won’t take long and I will take action to make sure that this never happens again.”