Portiuncula Hospital in County Galway has implemented a range of changes to improve care since a review of maternity care started in 2015.
Dr Pat Nash, group chief clinical director with Saolta University Health Care Group, apologised to the families affected.
I want to take the opportunity to apologise again to the families for the failures in the care identified and also for the length of time that this review has taken.
Earlier: Report into baby deaths at Galway hospital prompts call for urgent review across maternity services
A report into maternity services at Galway's Portiuncula University Hospital has identified multiple serious failures including poor communication and a lack of training to deal with emergency cases.
The report, commissioned in January 2015, examines the circumstances around the care of 18 babies at the hospital, some of whom died while others were left with life-changing injuries and disabilities.
The report is authored by UK-based Professor James Walker reveals that different management of obstetric care might have made a difference in 14 out of the 18 cases examined.
Specific findings - reported this evening by several media - include:
- A general lack of skills and training among front line staff.
- Lack of skills in the assessment of CTGs and the lack of access to quality ultrasound scanning and training
- Failure to identify pre-natal warning signs including abnormal foetal heartbeats.
- Failure to progress the delivery of the babies in a number of cases.
- The incorrect use of oxytocin, a drug given to mothers to speed up labour.
- Failure to bring serious cases to the attention of a senior doctor.
- Lack of midwives and consultants.
- Failure to openly disclose mistakes to parents.
The report also recounts how one family was contacted by the hospital while burying their child.
The HSE have apologised for the delay in issuing the report which was originally due in mid-2015.
“This has been a complex process and we have endeavoured to complete a rigorous review within the shortest possible timeframe.
"Nevertheless, we are conscious that these extended timelines can be very stressful for families and staff, especially to those who have waited many years for answers,” the report states.
Prof Walker also said the report was not about attributing blame but that all staff and national agencies must accept responsibility for what happened and actions required to ensure they did not happen again.
He also said it should be noted that Portiuncula has begun addressing many of the issues raised and progress had been made in this regard.
Reacting tonight AIMS Ireland said the report serves as yet another damning blow to the women of Ireland’s confidence in their health and maternity services.
AIMS Ireland is a voluntary organisation that was formed in early 2007 by women following their own experiences in the Irish maternity system.
In a statement tonight they called for urgent mandatory open disclosure, figures on mandatory training of HCPs in maternity services, geographical equality for service users and less heel-dragging on maternity strategy implementation.
“The report highlights that new technologies need to be rolled out rapidly. This is surely the point of a hub and spoke model of care. However this did not happen and it appears the care these babies received came down to a postcode lottery” said AIMS chair, Krysia Lynch.
“These cases in 2010 highlight the importance of both ongoing training for all staff and the role of the department of health and the HSE in ensuring a timely roll out of therapeutic treatments to all areas of the country. Where a treatment cannot be made available locally, there is a responsibility on the HSE to ensure that transport systems are in place.
"It is a sick joke to talk of reconfiguration and the development of hospital networks without investment in the necessary infrastructure to make this possible.”
She went on: “The blueprint for midwifery lead care as laid out in our maternity strategy needs to be implemented without delay. This model of care, which is the preference amongst service users we at AIMS represent.
“It is not just a nice extra available in some cities, it is an essential part of a safe, well functioning service as it frees obstetric care to focus on high risk cases.”
Speaking this afternoon the Minister for Health Simon Harris said the HSE and PUH have established a team to implement the recommendations and consult with affected families.
“I would like to convey my sympathies to the families involved and welcome the completion of this process for them. What we want to see now is action on the foot of this review and I have been informed by the HSE that this action is already underway."