Health boards have been ordered to review their protocols immediately to deal with emergency cases in light of what occurred in the baby Bronagh Livingstone case.
The order came last night from the Minister for Health, Mr Martin, when he published two reports on the circumstances surrounding the death last week of the premature baby. The reports were compiled by the North Eastern Health Board and a three-person independent review group.
The baby was born in an ambulance after her mother, Ms Denise Livingstone (32) was refused admission at Monaghan General Hospital and sent on a 25-mile journey to Cavan General Hospital. The baby was 24 weeks old and cried from the time of her birth until she arrived in Cavan, where she died within hours.
Mr Martin said lessons had to be learnt. The baby should have been allowed to have been born in Monaghan. He said Ms Livingstone's experience had been harrowing. "Having read the sequence and chronology of events, one can only have the greatest of sympathy for the Livingstone family.
"Denise Livingstone went through a terrible trauma and that's clear from the documentation that has been published. To give birth to a baby in an ambulance on the side of the road is a harrowing experience for any mother and then for that baby to die is even more traumatic and no words of mine will ever console Denise Livingstone or the Livingstone family. It is a matter of deep regret to me and for anybody who has any knowledge of this, that this event occurred," he said.
"There are very clear and very specific recommendations here and I'm saying to every health board, these have to be adopted and have to be put in place if they are not already in place, because this report does conclude that the existing protocols were not robust enough in Monaghan and there are significant criticisms of the process that led to the formulation of the protocols and their implementation. That is something that has to be put right immediately."
Mr Martin has appointed a management consultant to work with the board. Mr Kevin Bonnar, a former secretary general at the Department of Enterprise and Employment, will also work to ensure "an appropriate management structure" is put in place at Monaghan hospital.
The Minister added: "I would suggest that all parties and stakeholders involved here have lessons to learn and have to take on board the conclusions of this report. I will be meeting the health board to discuss the issues contained in this report in depth".
The Department was engaged in a wider analysis of health structures and on a preliminary analysis of the report's findings, "it seems to convince me even more" that the establishment of a national hospitals agency was essential.
He said the reports of the NEHB and the independent review group were at variance. The health board report did not have the breadth or senior clinical input required, but it had produced within 48 hours.
The Master of the Coombe Women's Hospital, Dr Sean Daly, who led the independent review, said the ambulance personnel deserved utmost praise. It was also almost impossible, he said, to say if the baby would have lived if Ms Livingstone had been admitted to Monaghan. The baby was "in very good condition" when she arrived in Cavan but it was "unfortunate and tragic" that she was only 24 weeks and six days old.
• The members of the Independent Review Panel appointed by the Minister for Health were: Dr Sean Daly, Master of Coombe Women's Hospital, Dublin; Ms Bridget Boyd, clinical nurse manager, neo-natal intensive care unit, Coombe Women's Hospital, and Ms Maureen P. Lynott, management consultant and head of the Department of Health's treatment purchase fund.