December 21, 2023, Health Minister Stephen Donnelly was interviewed on RTE’s News at One with Bryan Dobson, and asked about an Irish Examiner article referencing 21 baby deaths since 2013.

Bryan Dobson: “Minister before I let you go, perhaps I might get your reaction to a report this week in the Irish Examiner. It's in relation to deaths, baby deaths, postnatal deaths in hospitals over the last decade. Now, people will recall the situation in Portlaoise, which was highlighted by RTE some years ago. But the group Safer Births Ireland, in view of 21 deaths in the last decade - 16 of which were found at the inquest to be the result of medical misadventure - and what they're asking for is you as Minister for Health to order a review of baby deaths since 2013. What's your response?”

Minister Donnelly: “Well, can I say first of all, I have read the asks of Mel and Lisa Duffy and for anyone who's lost a much loved and most wanted baby it is absolutely devastating. And we take their calls and I take their calls very very seriously. There are important things that are happening this year.

“We've set up a new obstetrics events support team that's led by Dr. Peter McKenna, and it's examining incidences in maternity care. Critically, next year we're launching new national guidelines and they are speaking exactly to what Mel and Lisa Duffy are talking about, which is the monitoring of the heartbeat of the foetus and of the babies.

“Now what I've done is I've spoken with the National Patient Safety Office in my department. I've asked them to engage with the HSE on exactly the issues that Mel and Lisa are raising, and I've asked them to facilitate a meeting with Mel and Lisa so that the HSC and the National Women and Infant program can hear directly from them as to what their concerns are.

Mr Dobson: “What you've done so far, doesn't - though - meet this request for a review of those deaths over the last decade.”

Minister Donnelly: “What I want is for the HSE, the National Women and Infants program, to meet Mel and Lisa. I want them to listen very carefully.

“The advice I have for 21 Baby deaths where there was a coroner's Inquest is that there has been no trend identified in terms of baby heart monitoring.

“But what I imagine we will see is that the kind of actions that they're looking for around extra training for all maternity units, national guidelines to be put in place.

“They're the things we're working on, but it's always so important to listen directly to the people involved to hear from them what they want.

“And so that's the next step now, is a meeting where the HSE can hear directly from them as to what their concerns are, and walk through with them very important things that are happening next year in terms of training and national guidelines.”

On April 18, 2024, the Department of Health issued a statement in reponse to a question on April 17 from the Irish Examiner about where the advice Minister Donnelly had referenced on December 21 had come from.  That question came at the head of more than four months of repeated emails back and forth and FOI requests, trying to find out where the advice had come from, who gave it and what were the factual grounds for it in the first place. The FOI results shed no light on where the very specific advice the minister told RTE he had had at the time come from. There has also been no explanation about how he was advised about the list of 21 names referenced in the December 18, 2023 Irish Examiner story when neither he or any of his officials/advisers had the list before he spoke to Bryan Dobson on December 21.

The Department of Health statement is as follows: "When taking decisions in relation to clinical matters the Minister for Health relies on advice given to him or her by clinicians with specialist knowledge of the area under consideration.

“In the matter of maternity and neo-natal care that advice is provided to the Minister by the National Women & Infants Programme in the Health Service Executive (HSE), who have access to the highest level of clinical expertise in this area, and the National Patient Safety Office (NPSO) in the Department of Health who manage patient safety issues across the full range of care provided by our health service. In this instance, the Minister referred to the information provided in the FOI.

“However, relating to your specific question two issues were considered together in advising the Minister, and this clarity may help.

“Comprehensive and individual patient safety reviews and coroners’ reviews are conducted when required. In addition, there are significant and robust mechanisms which Ireland has in place to monitor the quality and safety of our maternity services.

“These mechanisms include data sources such as the National Perinatal Epidemiological Centre (NPEC) Reports and the Irish Maternity Indicator System (IMIS) that provide National Reports for National Women and Infants Health Programme (NWHIP).

“To clarify, these reports have not specifically identified trends in relation to baby heart monitoring. While trending data is one source of information and no specific trends are identified in the national reports, this is not considered in isolation.

“It is also well recognised clinically that failure to adequately interpret a cardio-tachograph (CTG) is often cited as a contributory factor in adverse event reviews, and in some coroner’s cases.

“It is also acknowledged, nationally and internationally, that CTG is an imperfect tool, that there are variations in practice and as such should always been used in conjunction with other monitoring techniques, such as the partogram and the woman’s vital signs.

“When it is recognised that there is potential for variations in practice, robust, evidence based national clinical guidelines should be developed along with training for staff to ensure consistent implementation.

“This is the approach that has been taken in Ireland to the interpretation of CTGs. The HSE is currently working on a comprehensive new guideline that will help to further standardise the process and will be incorporated into the training system.”