A Health Service Executive (HSE) review of maternity complaints has found compassion and sensitivity were not always demonstrated to patients.
The review examined patient complaints made between 1975 and 2015.
A Clinical Review Team examined the complaints, identified issues and made recommendations.
The review was initiated following an RTÉ 'Prime Time Investigates' programme in 2014, 'Fatal Failures'.
This programme revealed details of an investigation into the deaths of a number of babies over a six year period at the Maternity Unit in Midland Regional Hospital, Portlaoise.
These babies were alive at the onset of labour, but died either during the labour or within seven days of birth.
A total of 203 complaints were received at nine maternity hospitals over the 40-year period.
The HSE says 31 of them related specifically to peri-natal deaths (death of any baby from 24th week of gestation to one week after birth).
Of the total complaints, 153 patients consented to participate in the review process.
Some 130 complaints related to Midland Regional Hospital Portlaoise (MRHP), with 23 relating to eight other maternity hospitals.
These were:
- The Rotunda Hospital
- The Coombe Women and Infants University Hospital
- University Hospital Limerick
- Cork University Maternity Hospital
- Kerry General Hospital
- Midland Regional Hospital Mullingar
- Midland Regional Hospital Tullamore
- Galway University Hospital
The report found instances where care was considered not to be consistent with best practice.
It also identified serious deficits in patient communications, difficulties and delays in locating medical records and poor access to further support or care.
The review team has made recommendations - including patient apologies, referral of certain complaints for full analysis and 12 other specific recommendations.
This includes updating training in maternity units every two years, maintaining baby heartbeat monitoring equipment in good condition and immediate communication with a patient and family when they have a concern.
The report concludes: "To the parents, their families and loved ones, we would like to acknowledge that this has been a difficult and stressful process for many.
"We are aware that the length of time it took to complete the complaints review for the large number of participants has been hard, particularly for those who have lost a baby and who were seeking answers and anxious to have their complaints heard."
"Wake-up call to all of us"
Dr Susan O'Reilly, CEO of the Dublin Midlands Hospital Group, said: "It was important that patients’ complaints were heard, not least as it has served to inform and improve how we deliver and develop maternity services.
"The review team has endeavoured to answer questions, identify issues that needed further review or investigation, and make clear findings and recommendations."
"There is no doubt that the Midland Regional Hospital Portlaoise has had its challenges, but as acknowledged by HIQA, real improvements have been made.
"The recommendations contained in this review have been either implemented in full or are in progress.
"Management and staff at the hospital deliver high quality care every day, and are committed to continuous improvement. This review will further inform and drive this improvement."
Health Minister Simon Harris has welcomed the publication, acknowledging the bravery of those who took part.
"I would like to assure these women that the Government is committed to the progressive development of our maternity services", he said.
"It is regretted that it has taken such a long time for these issues to have full visibility. The number of these complaints over such a long period of time is a wake-up call to all of us to ensure our health system becomes more open, and deploys systems that are responsive and listen and learn from patients", he added.
