The HSE has acknowledged that its failure, “for several years, to acknowledge or address” the deficiencies in care that left baby Róisín Conroy permanently disabled, caused “unacceptable” additional stress to her family.
The apology, from Trevor O’Callaghan, chief executive of the Dublin Midlands Hospital Group, is contained in a newly published report examining the catalogue of failures at Portlaoise Hospital in November 2001, that ultimately left the infant only able to communicate with her eyes, and wheelchair bound, as a result of dyskinetic cerebral palsy.
Mr O’Callaghan also apologised for the length of time the investigation process has taken. The investigation commenced in April 2016 and was completed on May 9, 2018, nearly 17 years after Róisín was born.
The investigation team’s report outlined how, on November 13, 2001, Mary Conroy, of Dysart, Portlaoise, attended a routine antenatal appointment with her consultant. A scan suggested reduced amniotic fluid. As a result she was scheduled for admission to Portlaoise on November 14 for labour induction. Her consultant attended her in the morning and began the induction process but was not present for the labour or the delivery.
The report found even though Róisín’s cardiac trace was compromised, suggesting fetal distress, no obstetrician attended. An expert to the investigation process, obstetrician Dr Francois Gardeil, said it would have been “standard practice” to call a doctor if the patient is private, or if any abnormalities have been identified during labour by the midwife.
When the infant was delivered, the cord was tightly wrapped twice around her neck, she was “flat and unresponsive”, and had to be resuscitated.
During the investigation feedback process, Mrs Conroy and her husband “wished to highlight that they only became aware nine years after baby Róisín was delivered that an adverse incident occurred on November 14, 2001”. The report says the family highlighted throughout the process that their experience over the past 16 years “is critical to any learning from this incident”.
“Mrs Conroy and her husband understand, based on the feedback from staff during the investigation and previous legal proceedings, that medical and midwifery staff involved in the delivery of baby Róisín were aware at the time that an adverse event had occurred. However the family were not informed,” states the report.
“It is the opinion of Dr Gardeil that this lack of disclosure has had a negative impact on baby Róisín’s life expectancy.”
The report identifies two “key causal factors” that contributed to the injuries to Róisín, including failure to recognise fetal distress and failure to demonstrate proper professional duty during a high-risk labour.
The HSE said changes have been made to improve the standard of care, including new management and governance arrangements; investment in staff recruitment and training, and the signing of a memorandum of understanding between the HSE, on behalf of Portlaoise Hospital, and the Coombe, including the appointment of a clinical director to improve clinical integration and collaboration across maternity services within the hospital group.
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