In a January 2024 Briefing Note from the head of the National Women and Infants Health Program, it references a number of “current areas of concern”. It, for example, states “there have been concerns expressed over recent months that there is an increase in the number of perinatal deaths”.

It also stated that concerns had been expressed that a number of these cases have been found by the coroner to have occurred “as a result of inappropriate clinical management”.

The briefing note doesn’t say where these concerns were expressed. But they weren’t published in the Irish Examiner, because - up until 2021 - there hasn’t been an increase in the number of perinatal deaths. Added to that, while there have been a lot of inquests which resulted in a verdict of medical misadventure since 2013, none of the findings by any coroner have referenced any increase in perinatal mortality.

In accepting that - in effect - mistakes happen - the briefing note pointed out: “All elements of healthcare have adverse events.

“These are usually caused by systems or management of care, rather than by individuals. “From the reviews conducted into perinatal deaths in recent years, some of these babies may not have died with different clinical management. 

“Where this occurs, every effort is made to learn from these events to reduce the risk of recurrence.”

It also stated: “A lot of the adverse events that have been referenced recently relate to the period before 2018. 

“There have been very significant changes since that, however the HSE acknowledges that adverse events do still continue to occur.”

It is the case that 25 of the 53 babies the Irish Examiner has been reporting about died before 2018, but it is also the case that at least another 28 babies have died avoidable deaths between 2018 and 2022. 

However, as far as “every effort” being made to learn from adverse, the HSE has so far refused to say whether or not it has asked any of its 19 maternity units who reported any of the 488 Serious Reportable Events that were reported between 2020 and 2023 which ones resulted in a negative finding.

On August 1, the HSE confirmed it did not know how many investigations into any of those SREs resulted in a negative finding because none of the information is held centrally.

The HSE was then asked on September 17, 2024: "What has the HSE done since August 1 to find out how many of the 488 reported Serious Reportable Events (related to baby deaths and injuries in maternity unit) investigations in the past four years resulted in a negative finding? 

It was also asked: "Has, for example, the HSE contacted the masters of the relevant hospitals and asked them? 

“If nothing has been done and the HSE still doesn’t know - after 47 days - how many investigations into the 488 SREs resulted in a negative finding, why doesn’t it know?"

The response, on October 10, was: "We are not in a position to resource your queries at this time and have no further comment to make."