HSE’s failure to learn from mistakes is leading to more anguish

The RTÉ documentary into the deaths of babies at the Midland Regional Hospital in Portlaoise suggests a continuing failure by the Health Service Executive (HSE) to implement its own reports. At least one couple's baby might still be alive if failures identified in a previous case had been addressed.

Mark Molloy was born at the hospital in January 2012. He was alive at the onset of labour, but died shortly after being born. All four babies died either during labour or within seven days of birth. A common denominator in all four deaths was the presence of anoxia a oxygen starvation to the baby's brain.

None of the babies had congenital abnormalities or experienced severe infection, two of the common causes of perinatal death.

Foetal distress
During labour, mothers are closely monitored to ensure their babies are not experiencing foetal distress. This commonly manifests itself as a decelerated heartbeat; women in labour routinely have a monitoring device, to record the baby's heartbeat, as well as their own contractions, strapped to their abdomen. Referred to as a cardiotocograph (CTG), it provides a visual record of the baby's wellbeing.

According to the Prime Time report, some of the babies died because of a failure to act on signs of foetal distress. In other words, either staff were too busy to adequately monitor the CTG recordings or a health professional misinterpreted an abnormal reading as a normal finding. The discovery of two separate warning letters from all 32 midwifery staff at the maternity unit, predating the first death in 2008, suggests the facility may have been under-resourced.

Misused drug
It also found evidence that the drug Syntocinon may have been misused in the women concerned. This drug is designed to intensify womb contractions, thereby speeding up delivery. However, when used either in the wrong dose or on the wrong person it can cause problems, including foetal distress.

What is most worrying from the broad patient safety perspective is how the investigation into Mark Molloy’s death discovered that recommendations made following the death of another baby at Portlaoise in almost identical circumstances two years previously had not been implemented.

This is inexcusable. A similar missed chance to prevent a future fatality was identified in the report into the death of Savita Halappanavar. In her case it emerged that national recommendations for safer care contained in the report into the death of pregnant Drogheda woman Tanya McCabe had not been adequately followed up.

How much longer must we wait before predictable deaths in maternity hospitals are significantly reduced?