FOLLOWING ON FROM their January investigation into the death of four babies at the Midland Regional Hospital Portlaoise, RTÉ’s Prime Time programme tonight revealed more disturbing evidence, of non disclosure to patients in Portlaoise Hospital.
Fallout from the Fatal Failures programme earlier this year saw the Chief Medical Officer publish a report which found the maternity unit unsafe.
A HIQA investigation is also underway at the hospital.
CTG machine
The key failing was on the inability of staff to recognise or act on foetal distress which is monitored using a CTG machine. Hospital management repeatedly failed to act fully on recommendations to reduce this risk.
The babies that died in Portlaoise Hospital were, baby Katelyn who died in 2006, baby Nathan who died in 2008, baby Joshua who died in 2009 and baby Mark who died in 2012.
In tonight’s programme, they interviewed the parents of a fifth baby.
Amy Delahunt and Ollie Kelly from Borrisoleigh in County Tipperary talked to RTÉ about the death of their baby, Mary Kate, who died in May 2013.
At 34 weeks, Amy noticed her baby was not as active as normal – and attended the maternity unit at Portlaoise Hospital.
“They checked her baby by monitoring the heart rate on a CTG machine for an hour and 20 minutes,” said Amy, who said she was never told there was any risk to her baby and she was discharged.
The next morning she attended a regular scan at St Munchin’s Hospital in Limerick where she had been getting her maternity care.
Amy said:
I knew by the nurse’s reaction when she put on the scan we could see the baby there but we could see no movement and no heart beat, she just turned to us and she said unfortunately there’s no heart beat your baby is dead and sure that’s when it just went wrong.
A week later she delivered her baby, Mary Kate.
Wanting to know what had happened their baby the went to Limerick Hospital to review the case. Their consultant said she was not happy with Amy’s CTG and that if she had have seen it she never would have let Amy leave Portlaoise Hospital that day.
Portlaoise Hospital
They attended a meeting with Portlaoise six months after the death of their baby girl and recorded the meeting.
When we went into that meeting as we wanted to just know two things: find out what exactly happened and then say, right, what are we going to do? What have what have we to put in place to so it won’t happen again?
They were told by a consultant at Portlaoise that the CTG tracings were “abnormal” and when she had sat down to see this she was “absolutely gobsmacked”. She goes on to say that Amy should not have been discharged.
Amy and Ollie said they were happy the hospital had admitted a mistake had been made, they said and until they saw RTÉ’s last investigation into Portlaoise.
It was gut wrenching. We just we couldn’t believe it like We just couldn’t believe it like we were in tears watching it we just couldn’t credit that that all of this had happened… to four families before this, that they hadn’t learned from their mistakes, this was totally avoidable.
The reason for this is because Amy and Ollie were told in the meeting with the hospital that this had never been seen before, while families in RTÉ’s January investigation were also told that it was rare.
In the meeting with Portlaoise Hospital, Amy and Ollie ask in a straight forward manner is there anything else that they should know about the death of their daughter and they were told that everything they were told is what is known.
Review
In serious cases like this reviews are carried out, however families from January’s programme told RTÉ that they were not given copies of the reviews into their children’s deaths.
Amy and Ollie were not told of a review into Mary Kate’s death, despite it being HSE policy that they are to be informed when it is complete.
Instead, they were told that they could only access the report through a Freedom of Information request:
In February, it was revealed that the Department of Health were investigating the death of another baby at Portlaoise Hospital. Amy and Ollie heard this on the RTÉ News.
They said they were not informed by anyone that, in fact, the investigation taking place was into the death of their daughter
We were so angry. When we heard it on the news that there was a fifth case and Ollie said it could be us and I said no because you would imagine that if we were the fifth case that somebody would have contacted us before it was announced or even straight after it was announced, to tell us that it was being investigated.
A statement to RTÉ from the HSE stated:
…the review process…” in relation to Amy and Ollie’s case “…was inadequate…” and that an “…independent review will be commenced shortly with appropriate input from the family.
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