A report into the death of a baby at the Midlands Regional Hospital in Portlaoise has found significant failures in care provided to him and his mother.
Baby Joshua Keyes died shortly after he was born at the hospital on October 28th 2009.
The report by the Health Service Executive (HSE) into the death of baby Joshua has raised a number of concerns.
They centre on the interpretation of the foetal heart rate monitor - the CTG - the absence of foetal blood sampling at the hospital, the delay in delivery, and the care and support provided to his parents Shauna Keyes and Joseph Cornally following his death.
It makes 23 recommendations and the HSE has apologised unreservedly for the failings and the distress caused by the prolonged nature of the process, which led to the review.
The HSE says the findings of the report, and its 23 recommendations, have been implemented in the maternity services in Portlaoise Hospital.
The key measures taken to address these concerns include:
- Appointment of additional staff and increased staffing levels in the maternity unit in accordance with the Birth Rate Plus Study, including shift leaders on all duties
- Foetal blood sampling in place with continuous training
- Mandatory CTG monitoring training
- A number of new guidelines are in place including, the use of oxytocin, foetal heart monitoring and foetal blood sampling
- Provision of an oncall room in the labour ward for Obstetrician registrar onsite 24/7
- Lucas classification of urgency of caesarean section has been adopted into use and an individualised approach to assessment of urgency is in place
- The introduction of a guideline to support mothers and families experiencing neonatal death and the introduction of a bereavement committee and midwife with a special interest and training in bereavement support
The HSE adds that this report will also serve as "key driver" for the development of improved services in all maternity units throughout Ireland.
A National Implementation Group has also been established by the HSE to drive the action plan agreed arising from the Chief Medical Officer, HIQA and HSE reviews relating to Portlaoise.
Baby Joshua's parents requested the publication of the report after it emerged his death was investigated at the time, but they were never informed.
Joshua's mother Shauna Keyes says she hopes the Midlands Regional Hospital has learned from its mistakes.
"They have a cloud hanging over them at the moment - I'd hope that they'd learned lessons from what happened to all of our children (and) they're not going to allow it to happen again" she told Newstalk Lunchtime.
"Obviously mistakes will happen, they're humans at the end of the day, but it's how they approached it afterwards".
"Anybody I've spoken to who has lost a child in Portlaoise has said that it wasn't the death of their child that hurt them as badly as the lack of answers, the lack of facts and the time delays in getting those answers and facts" she added.
