Childbirth death report altered after manager’s input

CHANGES were made to the internal report into the death during childbirth of Garda Tania McCabe and her baby at Our Lady of Lourdes hospital two years ago after the manager of the HSE’s acute hospitals in the North East said he had “issues” with “nuances” in it.

This is revealed in a letter from the manager, Stephen Mulvany, which was released to local radio station LMFM under the Freedom of Information Act.

In it says he has “issues with aspects of specific wording and nuances/emphasis in the text”.

He said they were mostly around what “I would perceive as a possible under-emphasis on individual aspects of care management and a possible over-emphasis on systemic and resource issues”.

Louth Sinn Féin TD Arthur Morgan has accused Mr Mulvaney of “grossly overstepping the mark by seeming to suggest that staff should take the rap for her death”, and called for his resignation saying his position was now “untenable”.

The letter, marked urgent and strictly private and confidential, was sent by Mr Mulvany to the director of the National Hospitals Office in March last year.

It begins by saying the internal review into the death of Ms McCabe and one of her twin sons, Zach, was being conducted “in an open disclosure manner and has involved Ms McCabe’s family”.

However, Mr Mulvany then says he has met with the chairman of the review group, a consultant obstetrician at the Lourdes hospital, and a risk adviser and “I highlighted some areas for the review group to consider in terms of the format and text of the report”.

“Some of the areas highlighted by myself have led to revisions to the document.”

The letter also refers to legal advice the HSE had, which says the report exposes the HSE to a potentially significant legal liability and “international evidence would appear to be that in the long run legal issues and their financial impacts are likely to be reduced with the approach taken in the preparation of this report, including the linking in with the family”.

“In light of the above I would not propose to delay the report any further by seeking amendments to it,” he continued.

Mr Morgan says it is clear his priority was the HSE and not patients or staff.

“He sought to reduce the legal and financial impact of the incident on the HSE, rather than seek a full, open and honest report into the tragedy.”

He said the report is “seriously challenged and on that basis I believe he should resign. How can staff have any confidence in him as he tried to scapegoat them?”

The report concluded Ms McCabe died because it was not diagnosed that her waters had broken or that she had gone into septic shock. The inquest into her death concluded she died as a result of medical misadventure. Her son, Zach, had fatal congenital abnormalities.

Michael Reade, the LMFM journalist who sought the information under the Freedom of Information Act, said it came nearly a year after the station asked for answers to specific questions based on the recommendations in the report.

Last October, it began broadcasting a question every day as it sought to have them answered.

Yesterday the HSE issued a statement saying: “Mr Stephen Mulvany, hospital network manager, North East Hospitals, has confirmed he has always accepted in full the findings and recommendations of the report into the circumstances pertaining to the tragic death of Mrs Tania McCabe and her infant son, Zach, and this has been stated very publicly and formally at the time the report was published back in April 2008 and since then.”

It said that while the review, which he commissioned, was being carried out, “he had a duty” to “seek to understand the key issues, challenge and ask questions of the Independent Review Group who compiled the report but ultimately it was their report and that was always made clear to and accepted by the review group”.

“The HSE report is very direct and transparent about what went wrong in this tragic case and very significant progress has and is being made to fully implement its recommendations,” the statement added.

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