'Gobsmacked': HSE does not know outcome of probe into almost 500 baby deaths and injuries

Some of the 488 cases are defined as 'serious incidents' that 'may result in death or serious harm' while others are 'serious incidents' which need to be examined to determine if 'safety was compromised'. File picture

The HSE has said it does not know the outcome of investigations into almost 500 baby deaths and birth-related brain injuries over the past four years.

The Irish Examiner has confirmed that between 2020 and 2023, investigations were conducted in 488 cases where a baby was either stillborn, died within a month of birth, or suffered brain dysfunction.

The majority of the investigations have been completed but when asked what proportion of probes resulted in a negative finding, the HSE said the information is held locally in each hospital and not collated centrally on any HSE system. 

Advocates for improved maternity services say they are "gobsmacked" that the HSE does not know the outcomes of the cases.

All 488 cases were classified as care management events, which fall into the HSE category of Serious Reportable Events (SREs).

It is a mandatory requirement of the HSE that all Serious Reportable Events (SREs) are reported on the National Incident Management System (NIMS) and through the Safety Incident Management Communication/Escalation Form process.

There is not, however, a requirement for the results of any investigations to be reported back to NIMs after the four-month period in which they are due to be completed.

Some of the deaths are defined as serious incidents that “may result in death or serious harm” while others are serious incidents that need to be examined to determine if “safety was compromised”.

Investigations into SREs have to be launched within 48 hours and completed within four months.

A large number of the investigations (247) focused on stillborn babies, or those who died within a week of being born, between 2020 and 2023.

The deaths of a further 241 babies, who either died within a month of birth or who survived but suffered brain dysfunction, were also investigated.

Asked why it doesn’t know the outcomes of the 488 investigations, the HSE said the "primary responsibility and accountability for the effective management of incidents remains with the organisational level at which the incident occurs.

“So for these events, the management remains at hospital level."

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The HSE was asked why there is no mandatory requirement on hospitals to report the outcomes centrally.

The spokesperson replied: “NIMS is principally used for the purpose of learning from incidents and is not intended as a data collection system.

“NIMS data may contain anomalies and is subject to further change following ongoing incident and data analysis by services.”

A spokesperson for Safer Births Ireland said: “We are gobsmacked the HSE does not know the outcome of these investigations.

“How on earth can the HSE learn from these investigations if it does not have this information at its fingertips?”