INTERNAL EMAILS AT Portiuncula Hospital show how staff weren’t fully transparent with the parents of a child who died soon after birth.
RTÉ Investigates revealed tonight on Claire Byrne Live failures in care in the maternity services at the hospital in Ballinasloe.
The programme spoke to a number of families affected by the care at the hospital. One couple, Lorraine and Warren Reilly, lost two children at separate times around their birth.
Following the news in January 2015 that the HSE was reviewing the care of a number of babies in Portiuncula, Lorraine and Warren approached the health executive with their own cases.
It was in a meeting with the HSE that the couple first learned that a review had already been carried out by the hospital over the circumstances of Lorraine’s second baby’s death in 2011.
The cases around the care of their children were added to the HSE’s list of reviews in 2015.
The couple in recent weeks received their reports from the HSE review.
They received an unreserved apology for the failings in care provided at Portiuncula Hospital. The reports pointed out failings of care during both of Lorraine’s pregnancies.
In 2011, the Reillys applied under Data Protection legislation to Portiuncula Hospital for all documentation relating to them and their children.
Among this documentation was an email sent from a staff member to the hospital’s insurers, the States Claims Agency, in relation to the death of the Reilly’s second baby, Amber. The email stated:
Please see attached correspondence from the Coroner in relation to this case. This lady has since the inquest, contacted this office looking for copies of her medical records, which have been supplied…. Obviously, I am concerned that the coroner’s directive to carry out a review, will be discoverable. Can you please advise what is the best way to address this.
Following a review being carried out, it was sent to relevant staff in the hospital. Prompting this reply from one doctor:
“I believe a simple account of the chronology of the event ought to be sufficient.
“May I humbly suggest that much shortened versions sticking completely to the facts and indeed this rather prolonged version… both be submitted to the appropriate person in the clinical indemnity scheme and let them choose which one if any would be appropriate to return to [the coroner].
I don’t see any place in the correspondence with [the coroner] where a copy of this is required to be given to the parents of the deceased baby…
Lorraine and Warren were shocked at the correspondence.
“We just couldn’t believe what we were seeing, it was blatantly obvious that they were trying to cover their tracks,” Lorraine told RTÉ Investigates.
In a statement, the HSE Saolta Health Care Group – which has responsibility for Portiuncula Hospital – said:
Some of the internal communications identified from 2011 are very concerning and we do not condone the actions/views of others to which you refer… in particular the failure to include and communicate with Lorraine and Warren Reilly.
Baby Asha
In 2008 – at 30 weeks pregnant – Lorraine started to experience pain and so went to Portiuncula Hospital. The midwife informed her that she was likely in the early stages of labour and told her to wait as there was no bed available for her at the time.
About an hour passed, and Lorraine said she was in a lot of pain.
“I needed to go to the toilet so I got in and I had a massive bleed,” she told RTÉ Investigates.
Then they cleared a room for me, and they got me in straight away, there seemed to be four or five midwives then in very quickly with me and they started scanning trying to get a heartbeat then for Asha and I knew by their faces already that there was no heartbeat anymore.
Lorraine had suffered a massive placental abruption and baby Asha was delivered stillborn.
“She was brought out to me by one of the nurses and given to me in the waiting area outside the theatre and I just sat with her and talked to her constantly and cried,” said Lorraine.
Suppose we just wanted to cuddle her and take in everything before we had to say goodbye, we took photos and we just spent as much time as we could with her.
Second child
Lorraine and Warren believed that they were just unfortunate with what had happened. Two years later Lorraine was pregnant again.
She returned to Portiuncula Hospital when she was at her full-term and in labour.
After a midwife showed concern over the baby’s heartbeat, a consultant was called who asked that Lorraine be transferred to theatre for a caesarean section.
However this didn’t happen and Lorraine was only transferred to the theatre when the consultant arrived.
That night baby Amber was delivered. However she had been without oxygen for an unknown amount of time and was very sick.
“I remember looking at her and I turned around the Warren and I said we cannot lose another baby, I said this can’t happen again,” said Lorraine.
Baby Amber was transferred to the National Maternity Hospital in Dublin where she died six days later.
Lorraine said she and Warren were devastated.
I remember just throwing myself on top of the coffin, just over her and I’m saying no, you can’t take her now because I can’t do this again, I can’t do this a second time.
Lorraine and Warren believed at the time that they had been doubly unlucky and tried as best as they could to get on with their lives, only finding out years later what had happened.
Review
The HSE review into their care identified serious failings on behalf of the hospital.
Baby Asha’s review identified – among other things – a failure to recognise the signs of placental abruption and a failure to intervene to deliver the baby.
Baby Amber’s review concludes there was a failure to identify and respond to abnormal CTG tracings and a failure to follow the guideline in place for the management of a vaginal birth after caesarean.
In a statement to RTÉ the HSE Saolta Health Care Group said they have written to Lorraine and Warren Reilly “… to apologise unreservedly and fully for the failures of care delivered to Lorraine that contributed to the likely preventable deaths of Asha and Amber.”
After being supplied with the reviews into their children’s care, the Reillys called for the HSE to take real action on all of their recommendations.
“A lot of these is actually what was in Amber’s review in 2011 and they obviously were not implemented,” said Lorraine.
So now we have to make sure that they are implemented and we’re going to fight and we’re just going to be a nightmare for them because we’re just not going to let it go.
RTÉ stated that in the coming days the review team is to sign off on its final overall report on maternity practices at Portiuncula Hospital.
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