CUMH apologises for delay in telling mother of changes there since her baby son's death
Rachel Harrington and Pat O’Sullivan at the Cork City Coroner’s Court for the inquest into the death of their son Elijah in 2022. Ms Harrington has been emailing CUMH since her son’s inquest, to try and find out - among other things - if the coroner’s recommendations have been implemented.
Cork University Maternity Hospital staff have apologized to the mother of a baby who died in their care for delays she later faced when trying to find out what had changed at the hospital since his death.
The apology comes more than 16 months after the March 2024 inquest into Elijah O’Sullivan’s death on May 6, 2022, recorded a verdict of medical misadventure.
The Cork City Coroner's Court heard opportunities to save him were missed by staff a day after first-time mother Rachel Harrington, aged 25 at the time, presented to the hospital’s emergency department.
Although she was kept overnight and regularly monitored, a cardiotocography (CTG) of her baby's heart rate was later found to have been misinterpreted by one or more medics.
The Coroner’s Court heard a Serious Incident Management Team (SIMT) review of how the CTG result had been misinterpreted had been “completed” in time for last year’s inquest.
But it emerged, from evidence before the Cork City Coroner Philip Comyn, that the review was not completed because not all staff understood to have misinterpreted the CTG result had been asked by the SIMT team to explain their actions.
The court also heard that it took nearly two years to finalize the SIMT report into her son’s death.
One of Mr Comyn’s recommendations was that the SIMT process must be “carried out within 125 days from the adverse event”.
He also said the issues identified by the SIMT and necessary changes needing to be introduced should be conveyed to “all parties”.
Ms Harrington has been emailing CUMH since her son’s inquest, to try and find out - among other things - if Mr Comyn’s recommendations have been implemented.
A senior executive at the hospital told her via email last week: “Yes, all recommendations have been implemented. Recruitment to the Quality Office is ongoing and has been prioritised for 2025 to ensure the SIMT process is adequately resourced.
“The SIMT meeting is now a standing weekly meeting where cases are reviewed in a timely manner. Any items arising are discussed with senior members of the hospital management team and then directly with the staff members involved.”
They also confirmed that all SIMT reviews have taken place within the 125 days required after an adverse event since her son’s death in 2022.
The member of staff said: “I can confirm that all SIMT reviews are occurring within 125 days of occurrence and all notifiable incidents (as per the Patient Safety Act 2024) are finalised within this timeframe.”
In reply to a question about whether or not a process has been introduced whereby all medical personnel involved in an adverse event are all interviewed about what happened, they replied: “Yes, meeting with medical personnel involved in adverse events is part of the SIMT process.
“The members of the SIMT are responsible for reviewing and discussing any adverse or unexpected findings with the medical staff involved.”
The hospital also apologised for the amount of time it had taken to either complete the SIMT in her son’s case or to provide her with a copy of the report.
Of the delays in getting it to her, the hospital executive said: “This was an oversight and it should have been provided to you. I sincerely apologise for this lapse. The process was not timely and did not meet the standards you rightly expected."
“I am sincerely sorry for the delays and uncertainty you experienced at such a sad and difficult time and I deeply regret that this caused you additional distress.”
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