Chief executive of the HSE’s Dublin Midlands Hospital Group, Dr Susan O’Reilly, was commenting on the report of the death of baby Joshua Keyes.
He died at the Midland Regional Hospital, Portlaoise, in October 2009. The 90-page report into his death contains 23 recommendations.
Dr O’Reilly, speaking on RTÉ Radio, said the systems review was very thorough and all of the recommendations had been fully implemented.
The report was published at the request of the baby’s parents, Shauna Keyes and Joseph Cornally.
“The sad loss of their child has resulted in recommendations that are extremely helpful to us,” said Dr Reilly.
Among the recommendations are that there should be:
- Mandatory cardiotocography (CTG) — a technical means of recording the foetal heartbeat and uterine contractions while the baby is in the womb;
- Immediate access to foetal blood sampling if staff are not reassured by the CTG so as to have a relatively accurate assessment of the baby’s progress;
- Continuous training in foetal blood sampling, a technique used to inform decisions in high-risk pregnancies;
- Guidelines on the use of oxytocin, a medication used to start labour and increase the speed of labour;
- A new classification for Caesarean section and an individualised approach to assessment of urgency;
- A consultant obstetrician on call around the clock and that the on-call room is in the labour ward;
- A consistent approach to supporting mothers and families who have experienced neonatal death;
- A midwife with special interest and training in bereavement.
Also, health service staff attending a coroner’s inquest should be aware of how their demeanour and conduct may be interpreted by relatives and families.
The report recommends that waiting lists for antenatal booking clinics be actively monitored, with all women seen within the first three months of pregnancy, where possible.
An agreement has been signed by Portlaoise Hospital and the Coombe Women and Infants University Hospital to place its maternity unit under the control of the larger Dublin-based maternity hospital.
Recruitment is underway for the appointment of two consultant obstetricians that will be jointly appointed to both hospitals. Two additional neonatologists across both hospitals will also be appointed.
All maternity hospitals are now required to produce monthly safety statements.