DECEMBER 11, 2023 - to the HSE.

QUESTION: Yes or no - is the HSE doing any look back over all baby deaths in Ireland during any time frame since 2013 that resulted in a verdict at inquest of death by medical misadventure? 

QUESTION: Yes or no - is the HSE even aware that there have been more than 20 serious-incident baby deaths in the past ten years?

HSE REPLY: 

“Every adverse event is treated seriously by the HSE, and undergoes a review appropriate to the nature of the case, in line with the HSE’s Incident Management Framework. 

“Each is a tragic event for the family concerned, and the reviews try to provide answers as to the cause of the event. 

“The HSE also measures perinatal mortality and morbidity, to ensure that the best possible care can be provided to mothers and their babies.

“Every serious adverse event is covered by the HSE Incident Management Framework. 

“This Framework sets out the nature of the review that is required to review each of these events. 

“These reviews look at the individual circumstances of each case, and assess whether different clinical management may have resulted in a different outcome.

“In addition to reviewing individual cases, the HSE also measures perinatal morbidity data internationally by participating in the Vermont Oxford Network. 

“The National Perinatal Epidemiological Centre (NPEC) produces annual audits into perinatal mortality rates in Ireland, and this allows Ireland to benchmark against other comparable jurisdictions. 

“The HSE also produces an annual Therapeutic Hypothermia report, detailing the number of babies who require therapeutic hypothermia following a neonatal encephalopathy at birth.

“Ireland also participates in the MBRRACE confidential enquiry into maternal mortality, which provides very important data for service improvements.”

SEPTEMBER 19, 2023 - to the Dublin Midlands Hospital Group

QUESTION: Has anybody ever been reprimanded, punished, retrained, or held to account in any way for the deaths of babies of mothers in the care of Portlaoise Hospital where there was either a finding at inquest of misadventure or the baby's death was found to have been caused by a lack of care at the hospital?

QUESTION: Since the death of baby Luke Duffy in 2018 - for which the hospital subsequently apologised - is, as the Coroner recommended, there on-site consultant expertise available at all times for obstetric units and is it at all times accessible to medical staff and the nursing and midwifery teams of these units?

Midland Regional Hospital Portlaoise REPLY:

“The Midland Regional Hospital Portlaoise has implemented recommendations arising from past maternity cases that have been reviewed. 

“Maternity practices in Portlaoise Hospital are in accordance with national policies and procedures for Maternity Hospitals including publishing a Maternity Patient Safety Statement.

“We cannot comment publicly on the specifics relating to any individual case, as to do so would be a breach of the HSE’s obligation to maintain confidentially, we deeply regret the upset and distress any delays in the process causes families. It is recognised that any departure from the national standards is a source of enormous distress to bereaved families. 

“The Midland Regional Hospital Portlaoise take very seriously their responsibility in the care of women attending our maternity Hospital and the need to act in a sensitive, timely and appropriate manner when a woman and her family is going through an infant loss/perinatal death.”

DECEMBER 1, 2023 - to the HSE.

QUESTION: Is the HSE conducting or does it have any plans to conduct a review of baby deaths at the hospital since 2013?

QUESTION: If the HSE is not conducting a review of baby deaths in the past ten years at Portlaoise or planning to, is the HSE planning to or conducting a review of deaths over a shorter time frame, like between 2018 to 2021? If not look back/review, etc is underway to look at multipole baby deaths at Portlaoise, why is that?

QUESTION: If the HSE is aware of the deaths of Mary Kate Kelly (2013), Luke Duffy (2018) and Ódhran Murphy (2021) - whose deaths were found at inquests to have died as a result of medical misadventure - and the death of Aaron Cullen (2016), how concerned is the HSE concerned or alarmed by what has happened to those babies and by the lack of adherence to basic guidelines and practices maternity by staff at Portlaoise, as has emerged at every inquest?

QUESTION: In December 14, 2022, an audit report into compliance at Portlaoise with NCG for intrapartum fetal heart rate monitoring discovered that "maternity services at MRHP had not adopted the NCG to underpin fetal heart rate monitoring practices". How many other NCG audits have uncovered negative key audit findings like the non compliance of NCGs in the past six years?

HSE REPLY:

“The quality and safety of the maternity services is of utmost importance. We want to ensure the safety of all women and babies throughout the pre and postnatal period.

“The HSE has a number of reporting systems in place to monitor and share learning within the service. This includes both the Irish Maternity Indicator System (IMIS) Report and the monthly Maternity Safety Statements, which are used to monitor the quality and safety of the services. In addition the National Perinatal Epidemiological Centre (NPEC) produce reports on Perinatal Mortality, which looks at broader trends.

“Irish Maternity Indicator System (IMIS) - The HSE National Women and Infant’s Health Programme (NWIHP) Irish Maternity Indicator System (IMIS) National Report shows data from 19 maternity units. IMIS is an important management tool for the HSE in identifying any emerging trends in quality and safety metrics. Where the IMIS report identifies any outlier, there is direct engagement with the relevant maternity network to understand how the variations occurred, and any corrective action that may be required.

“Maternity Patient Safety Statements - Maternity Patient Safety Statements are published for each of the country’s 19 maternity hospitals and units, providing an updated statement each month. These statements provide public assurance that maternity services are delivered in an environment that promotes open disclosure. Each maternity hospital and unit reports on 17 metrics covering a range of clinical activities, major obstetric events, modes of delivery and clinical incidents.

“As per the National Maternity Strategy, the NWIHP will ensure that additional supports will be provided to pregnant women from vulnerable, disadvantaged groups or ethnic minorities, and will take account of the family’s determinants of health, such as socioeconomic circumstances. An online resource for maternity services has been developed, to act as a one-stop shop for all maternity-related information; any information provided will be understandable and culturally sensitive.

“In line with the National Maternity Strategy, NWIHP continues to promote and initiate high quality maternity healthcare which is safe, evidence-based, appropriate, timely, efficient, effective and equitable. 

“The Obstetric Event Support Team (OEST) provides support following an adverse event in maternity services with a focus on learning. The OEST forms part of the NWIHP’s Quality & Safety Framework and focuses on harvesting learning from severe adverse events, and sharing that learning around the country.

“Risk assessment forms an integral part of intrapartum care, influencing decisions about place of birth, methods of fetal monitoring, and timing and method of birth. When assessing how the baby is coping with labour maternal, fetal and labour factors as well as the fetal monitoring should be taken into account.

“The emphasis on regular assessment and checking on 'how the baby is?' is in line with the work of the Avoiding Brain Injury in Childbirth (ABC) collaboration by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, The Healthcare Improvement Studies (THIS) Institute.

“There is a need to be vigilant about changes in maternal or fetal conditions (such as increase in maternal temperature) with systematic assessment at least hourly in all settings to ensure that appropriate care is being offered and the holistic question “How is the baby?” is answered.”