There were “significant failings” in the care provided to a baby boy who died more than six years ago, a report published by the HSE has found.
The review into the death of baby Joshua Hayes at the Midland Regional Hospital, Portlaoise, in October 2009 highlights a number of key areas of concern.
Among the worrying issues is the interpretation of cardiotocography that measures a baby heartbeat and uterine contractions while the baby is in the womb.
Also of concern is the absence of foetal blood sampling, a technique used in obstetrics during labour to confirm whether fetal oxygenation is sufficient.
There was also the delay in the delivery of Joshua and the care and support provided to his mother after his death.
Joshua is one of a number of babies who have died in controversial circumstances at the hospital.
The HSE and the hospital repeated its “unreserved apology” to Shauna Keyes and Joseph Cornally for the failings that resulted in their son’s death.
The health authority and the hospital have also apologised for the distress caused because of the prolonged nature of the process that led to the review.
The report makes 23 recommendations, all of which have been implemented in the hospital’s maternity unit.
The systems’ analysis review was undertaken in 2014 as an independent review on the care of Joshua and his mother.
The HSE said it was designed to give the family all the information they need on the care they received.
It also lets hospital management know what kind of improvements are needed to reduce the risk of a similar baby death occurring again.
The health authority said many families had been affected by adverse outcomes in the country’s maternity services over the past number of year.
“The HSE deeply regrets the distress and anguish caused to these families for its failure to respond in a timely and empathetic way to these issues,” it stated.
“It is Shauna and Joseph’s expressed wish that the publication of Baby Joshua’s report will assist in ensuring that recommendations will be implemented nationally and, most importantly, to prevent unnecessary suffering, injury and loss of life.”
The independent review team described Shauna as a “remarkable woman” who supported other women who had experienced neonatal death while she was seeking answers in regard to her care.
The review examined four key areas of Shauna’s care — the management of her labour, the Caesarean section, the resuscitation of Joshua and the care and support provided to her following her son’s death.
It also found that, despite Joshua’s death being identified as an incident and formally reported, there was no evidence that it was the subject of a formal review process, as required.
A review was commissioned in March 2010 over the practice of a midwife at the unit and Shauna’s case was one of three considered.
The review that took two years to complete identified issues on the care of Shauna and the other two women and made a series of recommendations.
However, the review did not constitute a systems’ analysis and did not involve Shauna or the other mothers.
Shauna was not even aware at the time that the report had been commissioned.
It was when Shauna became aware of other concerns being raised regarding the maternity unit that she asked for a formal review.
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