Mullingar hospital inquest shows little has changed for those affected by tragedies
Open disclosure still missing in maternity units struggling to retain qualified staff
Kevin and Una Kelly leaving the Coroner’s Court. Their son Kevin James died six days after his birth in the Midland Regional Hospital, Mullingar. Photograph: Brenda Fitzsimons/The Irish Times
Every medical case – and every tragic hospital incident – is different, but the death of baby Kevin Kelly is worryingly similar to many recent events that have blighted the recent history of the health service.
Once again, the spotlight is on standards and staffing levels in small maternity units, which have less access to specialist expertise and a greater reliance on temporary staff than larger maternity hospitals in the main cities.
Since 2012, the spotlight has been on the failings identified in maternity services at Portlaoise hospital, but that controversy has raised questions about other maternity units in the middle of the country, including Mullingar.
Smaller units struggle to attract and retain qualified staff, and their throughput is often too small for staff to keep up their skills in dealing with complex pregnancies.
When Una Kelly was admitted to Mullingar in 2012, she was diagnosed as suffering from the potentially lethal condition of pre-eclampsia.
The ward was full and two midwives each had to care for 13 patients, according to evidence heard at baby Kevin’s inquest.
At various times during her stay, the labour ward was also full and she had to be treated elsewhere.
Many of the doctors who gave evidence to the inquest were locums, including the central witness, Dr Michael Osasare, who had worked in various hospitals around Ireland and has since left to work in Canada.
One midwife told the inquest she alerted Dr Osasare about a deceleration of baby Kevin’s heartbeat in the aftermath of a failed attempt to deliver him by forceps.
Dr Osasare said he remained unaware of this issue until later.
This failure in communication proved critical, because Ms Kelly was sent forward as a category two Caesarean, and 45 minutes elapsed before it took place. Dr Osasare said he would have made Ms Kelly a category one – or most urgent – case if he had realised something was wrong with the baby’s heartbeat.
This case also shows that dissatisfaction persists about the way the system deals with catastrophic hospital incidents among those most personally affected.
For all the talk about open disclosure and greater candour in the health service, this case appears to show little has changed.
Over 18 months on, the Ireland East Hospital Group, which includes Mullingar hospital, says the report into baby Kevin’s death “has not yet been finalised”.