Lorraine and Warren Reilly, who lost two baby girls in two years at Portiuncula University Hospital, have called for a “cultural shift” right up to the highest levels of management in the HSE.
Mr Reilly said every small maternity unit should examine the independent review of maternity services at Portiuncula Hospital and ensure there is no need for another one in the future.
“It is not just about Portiuncula Hospital, it is about all the small maternity units through Ireland; they all need a root and branch review,” he said.
The Reilly family from Loughrea, Co Galway, are among 16 families whose maternity care at the Ballinasloe hospital was reviewed.
They lost babies Asha and Amber in the hospital in 2008 and 2010. Asha was stillborn, while Amber, who was rushed to the National Maternity Hospital in Dublin, survived for a week.
Mr Reilly, speaking on RTÉ radio, said his two little girls could be alive had action been taken.
He and his wife, who have two other children, Angel, 11, and Caleb, 6, had wanted changes to be made so other families did not suffer the same outcomes.
However, it took a very long time for changes to be made and, sadly, other families did suffer.
In the report, the clinical review team states that of the 18 cases reviewed, serious errors in management occurred in 10 cases that would have probably made a difference to the outcome for those babies.
Of the 18 cases reviewed, six involved cases where the baby had died. In four of these cases, there were significant failings in the care provided to those babies.
Prof James Walker, who headed the review team, said when patient and family groups raise concerns about a hospital they should be tackled immediately.
“These big reviews are not the way to solve these problems; they should be tackled at a far lower level earlier. If there had been open disclosure at the time then this report would never have happened,” he said.
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