Deceased babies were transported in boot of a taxi

An especially distressing finding of the report was that highlighted by Dr Tony Holohan where dead babies were transported in the boot of a taxi to Tullamore hospital for postmortem.

The Chief Medical Officer’s review also found a baby suffered hypothermia on transfer to another hospital because an ambulance incubator was not working.

The investigation — to be followed by an inquiry by the Health Information and Quality Authority (Hiqa) — was sparked by repeated demands for answers by the parents of four babies who died in the unit.

It found the mothers and fathers were unfairly denied information on the deaths and treated with limited respect, kindness, courtesy and consideration after raising concerns.

Health Minister Dr James Reilly said he wants new rules ordering a coroner-led inquest if any baby dies once labour has commenced.

Dr Reilly disclosed that only one medic at Portlaoise has been subject to investigation by their relevant professional medical body over the mistreatment.

All four babies — Katelyn Keenan, Joshua Keyes-Cornally, Mark Molloy and Nathan Molyneaux — died either during labour or within seven days of birth at different times from 2006. A feature common to all of their deaths was anoxia, oxygen starvation to the brain. It is believed foetal distress was not recognised or acted on while mothers were in labour.

Calls for an independent inquiry were led by parents Mark and Roisin Molloy whose son, Mark, died 22 minutes after birth at the hospital on January 24, 2012. Mr Molloy said publication of the report was a vindication of their grievances but a day of mixed emotions.

“For us, when everything is implemented, when we have statistics we can rely on, safe maternity units, no one is going to say to us, ‘here, well done, have your little boy back’,” he said.

The Molloys, from Co Offaly, who had to seek to have their son’s death register changed from stillborn to newborn, sought explanations from the HSE for two years.

Dr Holohan’s damning review found a culture of insensitivity among staff in the Portlaoise maternity and paediatric units.

* Backs were being turned, honest accounts were not given, unprofessional behaviour and language was frequent and a lack of empathy common.

* Younger patients were spoken to through their mothers rather than directly, leaving them feeling judged.

* More than one member of the senior clinical staff invited families to sue.

nFurther distress was caused in the immediate aftermath of perinatal deaths — grieving mothers were not necessarily moved away from nursing mothers; practices for handling, dressing, bathing and photographing dead babies were at best variable; and appropriately sized coffins were not always available.

The chief medical officer said families who were refused information blamed themselves for something for which they had no responsibility. Two of the affected families met Dr Reilly and Dr Holohan in the wake of an RTÉ Prime Time programme this year which exposed the families’ quest for answers and treatment by hospital chiefs and prompted the inquiry.

Dr Holohan’s report, which includes a raft of recommendations on better maternity care, confirmed that information was withheld from families for no justifiable reason.

In a statement, the Health Service Executive (HSE) reiterated its apology for poor care when parents most needed compassion, candour and courtesy.

“The HSE and the hospital accept that there were significant shortcomings in the cases referred to in the report, particularly in relation to the level and quality of care afforded to the patients in question and to the sub-standard communications with their families.”

The review also identified failures at a national level. Some 1,983 births were recorded at Portlaoise in 2013 and 17,025 since 2006, but major discrepancies have been identified across the health system on how perinatal deaths and stillbirths are recorded. It said the current system was disparate and leads to confusion and duplication adding to the workload for maternity units and strain on scarce health service resources.

Dr Holohan’s report said data could have flagged suspicions of problems at the maternity unit.

The figures showed a significant rise in transfers out of Portlaoise for both maternity and paediatric care and a higher than expected rate of obstetric claims.

Dr Holohan’s report found: “While there was awareness that the service was under pressure, there does not appear to be any evidence that monitoring of how this might have been impacting on patient care was taking place.”

Action plan

The report’s main recommendations:

* That the hospital’s maternity services apologise unreservedly to the families and patients concerned;

* That Hiqa undertake an immediate assessment of the patient safety culture at Portlaoise Hospital;

* That a team be appointed to run the maternity services until it becomes part of a managed clinical network under a single governance model with the Coombe Hospital;

* That other small maternity services be incorporated into managed clinical networks within the relevant hospital group;

* That the HSE address the implications of the report for other services at Portlaoise Hospital;

* That support be provided to the Portlaoise Hospital senior management team, leading to a wider programme of support for frontline leaders, particularly in smaller hospitals;

* That Hiqa be requested to undertake an investigation in accordance with section 9 (2) of the Health Act 2007;

* That Hiqa develop national standards for the conduct of reviews of adverse incidents;

* That every maternity service (and later every health service provider) be required to complete a Patient Safety Statement which is published and updated monthly;

* That Hiqa establish a National Patient Safety Surveillance system.