Portlaoise hospital infant deaths
Micheál Martin raises the preventable deaths of four newborns and parents’ treatment at Portlaoise hospital, seeking an independent inquiry. The Taoiseach expresses grave concern and defends an immediate Chief Medical Officer’s report as the first step.
Last Thursday evening, an episode of "Prime Time Investigates", entitled "Fatal Failures", revealed a disturbing and unacceptable situation relating to the preventable deaths of four newborn babies over a period of six years. There were similarities between the deaths and reports were produced in respect of each fatality. I sympathise with the parents of the babies who died - unnecessarily, in my view - at Portlaoise hospital.
What shocked viewers of the programme was not only the manner of the care and the manner in which the babies died, but also the shocking way that the parents were treated subsequently by hospital management and HSE officials.
It is clear that there was secrecy in what was revealed to the parents. There was an unacceptable degree of obfuscation - of deliberately withholding the truth. Shockingly, in one case, we are looking at a two-year delay in letting the parents know that a report had been carried out into the death of their baby. In another case, the delay is up to five years. These parents never realised that a report had been carried out by the hospital which would have at least explained to some extent the why of what happened and could have helped the parents in dealing with a very tragic situation. It was only when Roisin Molloy heard Shauna Keyes describe her son Joshua's death that they came in contact. Shauna said it was like somebody lit a bulb in her head, such were the similarities of both their experiences.
There is the failure to implement the recommendations of reports into previous deaths at the hospital. These recommendations, if implemented, could have saved the lives of those babies who subsequently died. There were similarities in CTG tracings and an inappropriate use of drugs.
The point I want to make to the Taoiseach - I do this in a non-political way - is that in a situation like this we need to learn and a fully independent inquiry is called for. I do not believe health authorities can investigate themselves in situations such as this. I would ask him to ensure that a fully transparent inquiry independent of the health authorities would be carried out and that subsequently a wider review of maternity practice in the country would also be initiated and conducted.
Comment on this
It is a matter of the utmost sensitivity and seriousness that Deputy Martin raises. I do not think anybody can disagree with the sentiments expressed about the impact on parents of the death of their children, in this case, Nathan, Joshua and Mark. All parents can understand how that impacts on the parents' lives. This is a matter of the gravest concern.
The Minister for Health, Deputy Reilly, was deeply shocked by this programme and by the revelations that came therefrom. He spent six hours on Sunday with the parents of the children, in a private way talking to them about their stories and their feelings about what happened. He met Natasha Molyneaux, Shauna Keyes and Joey Cornally, and Roisin and Mark Molloy, all parents of exceptional diligence and commitment in wanting to find out the truth of what happened here. As one said, when she was transferred to a different hospital she felt treated like a mother.
The Minister wrote to the Chairman of the Joint Committee on Health and Children expressing grave concerns over a number of areas, not least the manner in which families were dealt with following the tragic death of their newborn infants. He is anxious that we would learn from these past mistakes, inefficiencies and tragedies and, therefore, parents must have proper, full and comprehensive access to information and communication about all of this.
The HSE will now meet all the families concerned to discuss how their legitimate complaints can be fully addressed. The Minister has instructed the Chief Medical Officer, Dr. Holohan, to prepare a report on the cases. That report will be of use to HIQA in deciding the scope and nature of investigations to take place.
The Minister for Health has clearly indicated that he is not happy with the situation in so far as Portlaoise hospital is concerned and that the hospital, no more than all others, should be in a position to provide a safe service to expectant mothers. Everybody knows the figures, in terms of safety for maternity and births in the country.
The Minister directed earlier this year that a new patient safety agency would be established this year. If this had been in place a number of years ago, these kind of cases might not have arisen in the first place. Everybody in the health service needs to understand that there are lessons to be learned from this kind of adverse event.
Finally, a national policy on open disclosure has been jointly developed by the HSE and the State Claims Agency and was launched by the Minister for Health in 2013. This is designed to have an open and consistent approach to communicating with patients when things go wrong in the health care area. That policy has been rolled out across the country.
It is not sufficient for people to say there have been inadequate budgets provided here. Portlaoise's has been reduced by less than 1%. Based on projected spending, not on historic budgets, the focus has to be on the delivery of absolute safety in respect of maternity for all the expectant mothers in the country. There is a proud record to be lived up to. Unfortunately, in these cases this was not so. The Minister has asked for a immediate response from the Chief Medical Officer and will obviously come back to the House on that.
Comment on this
I know the Chief Medical Officer. I have confidence in him, but that step is not the appropriate one to take. I beg to differ with that and it is no reflection on the Chief Medical Officer at all. In situations like this where there have been four deaths over the past six years, there should be a mechanism that triggers an immediate independent inquiry where all documentation and records can be accessed. That is the basic point I am putting to the Taoiseach.
In such a situation, there can be instinctive reactions, both on a campus and elsewhere. For example, the delay and the absolute obfuscation that occurred between the hospital management and the parents was quite shocking. It is truly shocking that reports were prepared on the death of their babies and the parents were not told for years afterwards. There are clinical and non-clinical issues here. There is clear maladministration here and it seems that a comprehensive inquiry at arm's length is called for. Ultimately, part of the strength of the response to the death of Ms Savita Halappanavar was the independent nature of the inquiry and its personnel. I would put it to the Taoiseach that that was effective in the end.
We can talk all we like about our good record but that is of no consolation to the parents concerned. If it was not for Mark and Roisin Molloy, the parents of baby Mark, I do not think we would be here today. Their tenacity and pursuit of this led to what we now know. I put it to the Taoiseach in good faith that when situations like this emerge the way to restore the confidence of the people in the services is for an independent inquiry to be held as soon as possible.
Comment on this
The seriousness of this is not underestimated. The Minister, Deputy Reilly, as a family doctor, was struck hard by the revelations in the RTE programme. That is why on Sunday he spent six hours in the company of a number of the parents.
Clearly, the system did not measure up here. The culture, in so far as the treatment of the mothers-to-be was concerned, was not what one would expect.
As a first step, what the Minister has commissioned is the right approach - namely to get the Chief Medical Officer to furnish him with an immediate report.
Last October the HIQA report on the death of Savita Halappanavar - God rest her - made recommendations on the safety, quality and standards of services for critically ill patients, including critically ill pregnant women. These recommendations are being implemented in full across the country. HIQA is completely independent in the way it does its business, but the first step is to allow the Minister to receive the report from the Chief Medical Officer. He is engaging with the parents concerned and the HSE will meet all of them. The Chairman of the Oireachtas Joint Committee on Health and Children has received a letter from the Minister, following his interest in this issue, expressing his grave concerns about a number of matters, a few of which the Deputy has mentioned. All of these issues need to be dealt with. There is a need for openness, communication and absolute transparency leading to trust and belief in the country's maternity services and safety for the women involved.
I know that Deputy Micheál Martin has not raised this matter in a party political way; it is an issue that transcends politics. It is about life, health, belief, standards and integrity which the Minister will ensure will apply in this case. I thank the Deputy for the way in which he has raised the matter.