Significant failings in the care given to a vulnerable young woman during her labour in Portlaoise hospital and after her baby’s death are identified in a HSE report.
The review of the death of baby Joshua Keyes-Cornally was published yesterday at the request of his parents, Shauna Keyes and Joseph Cornally, more than six years after his death in October 2009.
The report expresses concerns over the interpretation of the foetal heart rate monitor, the absence of foetal blood sampling at the hospital, the delay in delivery, the absence of a formal bereavement process and a lack of support for the family in relation to the coroner’s investigations.
The so-called systems analysis review commenced in 2014 with the purpose of establishing the factual circumstances of the case and informing hospital management what service improvements are required to reduce the risk of a future recurrence.
It quotes an expert finding that there was a failure to appreciate the CTG scan was abnormal several hours into labour.
Had foetal distress been correctly identified, it was likely a Caesarean section would have been performed more quickly, according to Dr Fionnuala McAuliffe, consultant obstetrician at the National Maternity Hospital.
was “a very vulnerable young woman for whom the significant impact of the neo-natal death of her baby should have been anticipated and managed in a person-centred manner which was particularly sensitive and empathetic,” the report states.
Publishing the report, the HSE and the hospital repeated earlier apologies for the failings that led to Joshua’s death and for “the levels of distress caused as a consequence of the prolonged nature of the process which led to the conduct of this review”.
“Many families have been affected by adverse outcomes in our maternity services over the past number of years. The HSE deeply regrets the distress and anguish caused to these families for its failure to respond in a timely and empathetic way to these issues.”
The report makes 23 recommendations which the HSE says have been implemented in Portlaoise.
These include the appointment of additional staff in the maternity unit, the provision of foetal blood sampling, mandatory training for foetal heart monitoring equipment and new guidelines on the use of oxytocin, which is used to accelerate labour.
The report says there is no doubt that Ms Keyes felt unsupported in her grief. Her issues included: Joshua died without herself or Mr Cornally being present; the grandparents were told about the death before Joshua’s parents; Joshua was squashed into a coffin that was “too small and too box-like”.
It was suggested she return to the labour ward after the death but she refused as “she would hear other babies cry and be reminded that her baby never would”.
The report says that despite baby Joshua’s death being identified as an incident and formally reported, there was no evidence of it being the subject of a formal review process as required by HSE policy and regional guidelines.
A review of this and two other cases was eventually begun in 2010 but took two years to complete. Ms Keyes was not interviewed for this process and remained unaware at the time it was being carried out.
An inquest wasn’t held until September 2013, nearly four years after the death. Ms Keyes believed this happened only because of her “continued insistence” rather than it being a planned event.
Asked about the “perceived delay” in holding the inquest, the coroner referred to a difficulty in assembling the required information from contemporaneous records.
Details of Joshua's death first emerged in a report on his inquest in The Irish Times. Since then, further details of other baby deaths in Portlaoise emerged and two official reports were commissioned in the wake of an RTÉ Prime Time programme on the deaths two years ago.
Ms Keyes said the publication of the report marked the end of a journey. “It’s finally our closure,” she said, adding that she was pleased the HSE apologised over the death.
She said it should not have taken more than six years for this matter to come to a conclusion. “It’s just about getting to the point now where I can close the door on all this and try to move on with my daughter,” she told RTÉ radio.