This is a personal site to help draw attention not just to avoidable preventable hospital baby deaths in Ireland, but also the avoidable preventable injuries to babies at birth.

It is not in any way owned, funded or run by the Irish Examiner, where I work as a reporter. This is a collection of articles written by myself and other journalists and of questions asked and answers given.

While there is little or nothing anybody can do about a proportion of babies who will die - a proportion should not have died and official acknowledgement about their deaths mostly only comes after the grieving families have been through an inquest.

As well as dealing with the emotional and psychological impact of baby loss, most of the parents are forever searching for the answers to basic questions prefaced with the word “Why?”

Why did their baby die?

Why did maternity nurses not know that back pain is the signs of labour?

Why was the consultant not available?

Why were there deficits in staff training?

Why were national standards and guidelines not adhered to and who was tasked with checking if they were?

Why did staff not realise a baby was struggling to breath?

Why was a diagnosis missed?

Why was the wrong diagnosis made?

Why was delivery delayed?

Why was mum not listened to?

Why did so many midwives - as happened in at least one case - not realize the baby was in the breach position before they died?

Why did management not have enough staff on duty?

Why were not enough resources put into hiring qualified staff?

Why were staff so exhausted ?

Why didn’t hospital management invest in more diagnostics?

Why didn’t they have such and such a scanner?

Why did such and such a senior medic suddenly - at an inquest - just forget what happened in the build up to the death of a baby?

The annual Perinatal Mortality Rate stats do not reflect avoidable preventable baby deaths, which get little or no recognition, and are obscured behind any public presentation of some of the unfortunate down sides to Irish maternity services.

At best, the HSE will tell you “some” babies who died might have survived if their care and the care of their mother had been handled differently, and then they will tell you about the bodies, committees, review groups, discussion groups, etc they have set up and they will present you with a panoply of other things - which, in fairness, are very good - they do.

They won’t, however, talk to you in any great depth about the babies who die avoidable deaths or the babies that suffer life-changing and avoidable birth injuries.

They could have a very rich source of data on baby deaths and injuries if they collated nationally the results of the more than 500 Serious Reportable Events reports, but have to far not publicly explained whether or not they will do this. They will tell you they aren’t doing it because they don’t do it, and they will tell you that not every SRE ends up in an investigation. Grand, but it is truly extraordinary that they can’t say how many of these SRE reports resulted in a negative outcome.

One would hope or expect that the percentage would be low but again, nobody knows in head office because they don’t check.

Instead, the HSE has now launched a “Confidential” inquiry into baby death data it already has.

Although the objective of calling in the results of SREs and looking at what went wrong would have the same purpose as such an inquiry but involve fewer staff and take a shorter amount of time, the HSE has chosen not to do this.

There is no doubting the experience of most mothers in Irish maternity units ends positively.

The fact that so many babies are born alive and well in Ireland is obvious testament to that. But bad things are happening, time and time again, regardless of all the repeated assurances about lessons being learned, the reports, the apologies, and never-ending initiatives.

I got more involved recently after covering inquests of babies who died after being born at Portlaoise Hospital after the original 2014 so-called Portlaoise Baby Scandal broken by RTE Investigates’ reporter Aoife Hegarty .

I was alerted to their deaths by Roisin Molloy, whose son Mark died there after a series of failings that both herself and her husband Mark Senior fought ten years to help ensure would never be repeated. They gave up ten years of their lives to see through major changes in maternity services. They made a huge difference.

Like so many other journalists who covered the original Portlaoise Baby Scandal after it broke, I thought there were so many changes for the better in place now in maternity services that the problem of avoidable baby deaths and injuries was simply not as much of a problem anymore, or certainly not as big as it was when a light was shone on the issue in 2014 by RTE.

But I have since discovered that I was wrong.

The first inquest that set me down this renewed investigative path was that of Luke Duffy, whose mother Lisa was last year in the process of formally launching Safer Births Ireland with another grieving mother, Claire Cullen.

I started a database last year of avoidable preventable baby deaths and with Lisa and Claire’s help that list has grown.

It now has 63 names on it, and I am also aware of another ten or so cases I have been asked to look at, and I am working through those. 

As much as this site tries to be a factual presentation of what is a national scandal hiding in plain sight, it is also (in its own way) a tribute to those women who are fighting to find out why their babies died.

Those parents will never get to share the usual landmarks on their baby’s life, and every year they will be reminded about those landmarks.

If you want to tell me your story about avoidable preventable baby loss or injury either in strict confidence or on-the-record, please email me at neil.michael @ examiner . ie