Publish reports into baby deaths - grieving mum
The mother of a baby who died in Portlaoise Hospital has said it is "no longer tolerable" that investigation reports into infant deaths aren't automatically published if parents have given their permission.
Roisin Molloy and her husband Mark pleaded with the HSE for two years to release the report into their son Mark's death at the hospital in January 2012.
It was finally published yesterday after a campaign by the Co Offaly couple.
"These reports should not be kept hidden away. They provide an opportunity for shared learning - not just in the hospital where the baby died but in all maternity units across the country.
"The policy of containment where reports are not released is no longer tolerable.
"Baby Mark's report is now on the HSE website.
"It is what we repeatedly asked for and now it is open to others involved in maternity care to access it and learn lessons," said Mrs Molloy.
The report, completed two years ago, contains the CTG trace of baby Mark, which charts some of his final moments.
It highlights the failure of hospital staff to act on signs of foetal distress and fully assess all sections of the CTG reading.
This led to Mrs Molloy inappropriately being given the drug syntocinon to speed up labour even though this added further to the unborn baby's distress and a fall in oxygen.
There was also delay in transferring Mrs Molloy to the operating theatre for delivery. The baby died 22 minutes after his birth.
His death was recorded as a stillbirth and his family faced a struggle to find out the real reason why their baby died.
Baby Mark was one of five infants who died in similar circumstances in Portlaoise Hospital over a number of years.
It was only after the Molloy family went public with other bereaved parents that the Health Information and Quality Authority (HIQA) was asked to carry out an investigation, producing a damning report.
The HSE yesterday reiterated its unreserved apology to the Molloy family for the failings, distress and anguish caused to them.
It said these reviews as "tools for hospital management are as such not typically published".
The HSE said that the 43 recommendations in the report have been implemented in Portlaoise and in other hospitals.
These include the appointment of more midwifery and specialist nursing staff. Staff also have to undergo mandatory training in CTG tracing.
The report stressed the need for proper bereavement systems to be put in place.
They include allowing parents to have a momento such as a lock of hair or a foot print.