HSE failings ‘led to five deaths, injured 80 babies, and cost the State €320m’
Midland Regional Hospital, Portlaoise
Health service failings that led to five deaths in the 2014 Portlaoise baby deaths scandal also contributed to life-changing injuries to up to 80 babies and cost the State up to €320m in compensation, according to a review of catastrophic baby injury claims.
The review, by the State Claims Agency (SCA), found nurses failed to monitor fetal heart rates “appropriately” in just over half of claims the agency reviewed.
It also noted staff “failed to interpret or recognise” abnormal CTG trace results in more than 60% of claims over a five-year period.
In addition, 77% of claims related to injuries sustained before or during labour where there was a delayed delivery.
The SCA also noted that 43% of the 80 claims reviewed also involved women whose labour was “accelerated” by one of, or both of, two common labour-inducing methods.
These were either doses of synthetic forms of the labour-inducing hormone oxytocin, the artificial rupture of membranes, also known as breaking the waters, or both.
The review also noted there had been an “inappropriate” use of oxytocin in 36% of cases.
The SCA’s review was carried out on claims completed between 2015 and 2019, involving cases brought between one and six years after the HSE vowed to bring in wide-ranging maternity service changes in 2013.
This included mandatory cardiotocography (CTG) trace training for maternity staff in the wake of baby deaths in Portlaoise.
A 2013 systems analysis review into the 2012 death of Mark Molloy, one of five babies who died in Portlaoise Hospital between 2006 and 2012, had revealed poorly-trained staff had not interpreted a CTG trace result in Mark’s care as “abnormal”.
This led to the inappropriate use of Syntocinon, a manufactured form of the birth hormone oxytocin, and a delay in his delivery.
The HSE vowed its review into his case would be “a key driver” for the development of improved services in “all maternity units”.
As well as the review in 2013, the health watchdog Hiqa also brought out a damning report that year into the safety standards of HSE maternity services.
It was conducted after Savita Halappanavar died of sepsis in 2012 after having repeatedly asked for an abortion over two days, as her 17-week-old baby was dying.
As well as the constitutional issues it raised around abortion, Hiqa concluded there were within the HSE “concerning deficits in how learning — particularly in the areas of maternity services — has been adopted and implemented following previous investigations and inquiries”.
It also flagged the HSE’s “inability to apply system-wide learning from adverse findings”.
A spokesperson for the advocacy group Safer Births Ireland said: “After all the reports and recommendations from Portlaoise and Savita, it is shocking the same issues keep popping up. Given these and other issues have been playing a part in baby deaths and injuries for years, the State Claims Agency review is especially disturbing.
“The CAS report highlights the need for the in-depth inquiry we and other maternity service reform advocates have been calling for since 2023.
The SCA defines a catastrophic birth injury claim as one where a birth injury results in serious disability and or permanent incapacity to a baby, or where the estimated liability is over €4m.
It stated the aim of its Catastrophic Claims relating to Babies in Maternity Services Review Report is to “present the key findings, key learnings, and advice for maternity units to help mitigate the risk of similar claims occurring”.
It added: “Catastrophic birth injuries exact a high toll physically, emotionally, and financially on people affected, in addition to the financial cost to the State.”
The amount of outstanding catastrophic clinical injury claims was just over €3 billion in 2023, out of the total of €5.1bn outstanding liabilities.
The HSE was asked for a comment about the SCA report but was unavailable for comment.
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