Timeline: How events unfolded at Portiuncula Hospital
Review that was expected to last five months ended up taking more than three years
Portiuncula Hospital Ballinasloe. Photograph: Alan Betson/The Irish Times
October 2014: Portiuncula Hospital identifies as an “unusual trend” the transfer of four newborns to Dublin for head-cooling, a treatment used to minimise the effect of oxygen deprivation.
November: Three more cases, including a neonatal death, identified. Review into seven cases ordered by Saolta hospital group. Senior HSE management in Dublin informed.
December 5th: Preliminary review raises “serious concerns” about labour practices. Measures put in place to address risk.
December 16th: Audit of 22 deliveries since measures were put in place finds four cases of significant concern.
December 21st: Preliminary review report completed (unpublished).
December 22nd: Minister for Health Leo Varadkar in meeting about maternity services in Portlaoise; problems at Portiuncula not referred to.
December 23rd: Saolta instructs hospital to implement “protective measures” and says full review of maternity services will be carried out and seven women will be informed.
December 29th: HSE director general Tony O’Brien and Dr Tony Holohan, chief medical officer at Department of Health, are informed of issues at Portiuncula.
December 30th: Dr Holohan expresses surprise as this is first the Department has heard of issues at Portiuncula.
January 2015: Department and HSE clash over escalation of the issue to national level and seriousness of situation. HSE resists apologising to families at this stage. Delay in informing women and setting up inquiry.
January 22nd: Problems at Portiuncula revealed in the media. Saolta issues statement expressing regret at distress caused.
February: Inquiry into Portiuncula expanded to cover at least 12 cases. Independent UK-based chairman appointed to head investigation.
November 2017: A jury deliver a verdict of medical misadventure at the inquest of Asha Reilly, who was still born in Portiuncula in 2008. The hospital also apologies to her parents, Lorraine and Warren Reilly, who lost a second baby there, Amber, in 2010.
May 2018: Investigation report is finally published, more than three years after it was announced.