No attempt should have been made to transfer Ms Denise Livingstone to Cavan General Hospital when she presented at Monaghan General Hospital in an advanced stage of labour last week, according to independent experts.
Their highly critical report on her treatment and the subsequent death of her premature baby, published late last night, said a team from Cavan hospital or Our Lady of Lourdes Hospital in Drogheda should have been requested to travel to Monaghan as quickly as possible to attend to the 32-year-old woman, from Emyvale, when she presented at Monaghan hospital at 5.15 a.m on December 11th.
Ms Livingstone was refused admission to Monaghan hospital because maternity services were controversially suspended there last year. She was sent instead in an ambulance to Cavan, unaccompanied by a doctor or nurse, and en route gave birth to a premature baby girl, Bronagh, who died later at Cavan hospital.
The independent review of Ms Livingstone's case, commissioned by the Minister for Health, conflicts with a report on the incident carried out by the North Eastern Health Board (NEHB), which is responsible for Monaghan hospital. This was also published last night by Mr Martin.
The independent report said she should have been accompanied in the ambulance by a nurse or midwife. This should be "mandatory". The health board had claimed Ms Livingstone's care had not been compromised by the absence of a midwife. The independent experts said the ambulance personnel requested a midwife to accompany them but were told by a nurse that none was available. The baby was born at 6 a.m. and died at 8.55 a.m.
The NEHB report also said it believed the decision to transfer Ms Livingstone to Cavan was the correct one. However, the independent experts said: "In our opinion Bronagh Livingstone's birth was imminent shortly after she arrived at Monaghan General Hospital. Consequently, no attempt should have been made to transfer Ms Livingstone to Cavan General Hospital prior to delivery."
They said the consultant anaesthetist on call should have been brought in and the equipment in Monaghan, which was excellent, should have been mobilised to stabilise the baby in the event of its delivery prior to its transfer.
Last night Mr Martin ordered an immediate review of protocols to deal with emergency cases in all health board areas. He said Ms Livingstone's experience had been "harrowing".
He announced the appointment of Mr Kevin Bonnar, a senior management consultant, to ensure the report's recommendations were implemented by the NEHB.
The NEHB, in a statement, said it would fully co-operate with Mr Bonnar but it needed time to analyse the report.
The independent review was carried out by Dr Sean Daly, master of the Coombe Women's Hospital; Ms Maureen Lynott, management consultant and head of the Treatment Purchase Fund; and Ms Bridget Boyd, clinical nurse manager at the neo-natal intensive care unit at the Coombe.
They said: "The surgical SHO (senior house officer) did not, in our opinion, adequately examine Ms Livingstone" in Monaghan. He did not believe she was in labour but believed she would be accompanied in the ambulance. However, he did not ensure this happened. The report said he should have contacted his consultant.
The actions of staff on the night were not predicated upon fear of reprimand, they added. Furthermore, they said it was clear the ongoing controversy surrounding Monaghan hospital had a part to play. The staff were "caught in the middle between their employer, the NEHB, local factions within and outside of the hospital, and their loyalty and ties in the community. There is widespread anxiety and mistrust and not surprisingly this has affected staff confidence and morale ... in such circumstances there is vulnerability to error".