Confidential inquiry will investigate newborn deaths over three-year period

The worst year recently for potentially avoidable hospital baby deaths was 2018, when at least 10 newborns died.

An inquiry has been launched into still and newborn baby deaths over a three-year period.

The National Women and Infants Health Programme (NWIHP) is due to start the inquiry later this year.

The body, which leads maternity, gynaecology, and neonatal services, is currently working on the terms of reference.

Described as a “confidential inquiry”, it will look into cases identified from existing perinatal death audit data from the National Perinatal Epidemiology Centre (NPEC), based in Cork.

The inquiry will be overseen by members of the NWIHP and NPEC as well as members of the public.

A HSE spokesperson told the Irish Examiner: "The enquiry will report on three years’ worth of data at a time. It will commence this year and report on the period 2021-2023.

“A report will be produced annually, with another year’s data being added (and the earliest being removed).

“The cases will be identified from the NPEC perinatal death audit data, which are already being reported.” 

Case notes on baby deaths will need to be accessed to determine which disciplines are required for each case.

The cases will then be assigned to an appropriate panel of assessors.

According to the HSE, assessors chosen to work on the inquiry will be drawn from specialties including obstetrics, midwifery, neonatology, neonatal nursing, perinatal pathology fetal medicine, and anaesthesiology.

There have been repeated calls for a look back over baby deaths following a survey by the Irish Examiner last year of 51 mostly avoidable baby deaths since 2013 that were mostly dealt with at an inquest, but which also resulted in High Court proceedings.

It revealed a litany of failings in the care of those who died.

They included mothers-to-be classed as high risk but who were not treated as such, and for whom extra scans and checks were not done.

In at least 21 of the deaths, issues around fetal heart-beat monitoring (CTG) were raised either at inquest or in the High Court.

Issues also include women saying their wishes were not acted on or were ignored, delayed deliveries and delayed or missed diagnosis of various conditions - including maternity nurses in a small number of cases even missing the fact that a woman was in labour.

The worst year for potentially avoidable hospital baby deaths since 2013 was 2018, when at least 10 babies died - three of them at the same hospital over a five-month period.

At least 18 of the inquests resulted in verdicts of medical misadventure.

A spokesperson for Safer Births Ireland, which is campaigning for a Commission of Investigation into mother and baby deaths and injuries, said: “We were unaware that such a confidential inquiry was launched.

As a result, we have no idea to what extent bereaved parents will end up being involved, or to what extent they will or have already been involved in the setting the terms of reference.

“But if this does end up being a process where parents are front and centre of it, then we would welcome it."

As well as this inquiry, there is also the ongoing NPEC Coronial Investigation into Perinatal Deaths. This includes a scoping review into the role of coroners in perinatal death investigations in “high-income countries”.