Portlaoise Hospital baby deaths: Is history repeating itself? 

The number of baby deaths across Ireland that are similar in circumstance and ruled as medical misadventure continues despite revelations a decade ago about Portlaoise Hospital and calls for an external investigation, writes Neil Michael
Portlaoise Hospital baby deaths: Is history repeating itself? 

(Left to right) Ann Dunne (Hilary’s mother), Hilary and Paddy Murphy, and Paddy's father, Pat, at an inquest in Portlaoise into the death of their baby son Ódhran. Picture: Neil Michael

There were nine empty chairs this Christmas at the dinner tables of mothers who have attended Portlaoise Hospital maternity unit in the last 17 years.

Four should have been occupied by teenagers; and another four by younger children, still giddy with the magic of the holiday. The last chair should have a smiling toddler in it.

Katelyn McCarthy would be 17, Dylan Franks 16, Nathan Molyneaux 15, Joshua Keyes 14, and Mark Molloy turning 12 in January. Mary Kate Kelly should be 10, Aaron Cullen seven, Luke Duffy five, and Ódhran Murphy would have been two on December 27.

In each of those homes, there will always be a framed photograph, a space where another bed should have been, and teddies that lost out on cuddles from little hands.

And in their parents’ hearts, there will always be a missing piece.

Sadly, what was a scandal nearly a decade ago at Portlaoise Hospital’s maternity unit now appears to be repeating itself.

An RTÉ expose in January 2014 revealed that four babies had died between 2006 and 2014 and, later, it emerged there was a fifth — Dylan.

The first, Katelyn, died in 2006.

Mark, the last baby whose death was investigated in reports into the Portlaoise maternity unit, died in 2012.

That all their deaths had similarities was alarming.

But the fact that their parents had to fight hard just to get answers compounded matters.

Report after report would say the same thing: That staff at the hospital had failed to spot fetal distress in time.

Other issues were inappropriate prescription of labour-inducing drugs, the inability to properly monitor fetal heart rates, and delays in delivery.

The lack of available obstetric staff or timely obstetric opinion was also flagged, as was training and neglect of basic procedures.

Time and time again, the reports found that mothers were not heard, that if they hadn’t been misled, or had their babies’ medical notes altered, they were simply kept in the dark.

The report was an appalling and unedifying insight into how women were treated, but the issues were not unique to Portlaoise.

More babies, some of their deaths later ruled at inquest to be medical misadventure, had also died in Cavan General Hospital.

While four baby deaths were investigated there, baby deaths since have resulted in verdicts of medical misadventure.

What was exposed at Portlaoise led to other hospital practices being examined.

'Not unique'

Association for Improvements in Maternity Services Ireland (Aims Ireland) chairperson, Krysia Lynch, said that what was happening in Portlaoise was not unique.

“It was a reflection of a wider problem right around the country,” she said. “Describing it as the canary in the coal mine is a very good way of putting it.”

The health campaigner is one of a growing number of people looking at Portlaoise with renewed alarm.

Since 2013, at least four baby deaths have had similar — if not identical — issues to the ones that arose in the Portlaoise scandal.

Mel and Lisa Duffy, from Mountrath, Co Laois, outside Portlaoise Coroner's Court after the inquest into the death of their baby son Luke, who died at Portlaoise Hospital on October 29, 2018. They are holding a framed photo of baby Luke after he was stillborn. Picture: Neil Michael
Mel and Lisa Duffy, from Mountrath, Co Laois, outside Portlaoise Coroner's Court after the inquest into the death of their baby son Luke, who died at Portlaoise Hospital on October 29, 2018. They are holding a framed photo of baby Luke after he was stillborn. Picture: Neil Michael

Three of the babies — Mary Kate, Luke, and Ódhran — were found at inquests to have died as a result of medical misadventure.

The coroner into the death of the fourth baby, Aaron, initially gave a narrative verdict.

However, she has recently agreed to hold another inquest next year — a highly unusual move.

Yet another inquest, into another baby death, is due to take place early next year, it is understood, while the Irish Examiner has been told that a handful of other baby deaths have question marks over them.

“It would be a bit of an understatement to suggest that history is repeating itself in Portlaoise,” Ms Lynch said.

“I would love to know what the Department of Health and the minister of health are doing about this.

"I have already called for an investigation, but think it has fallen on deaf ears. What is happening is scandalous.”

Ms Lynch said that any investigation needs to be external.

“If you want to find out what has happened in Ireland, in a medical context, at least, you have to get someone from a different country to investigate,” she said.

Damning report

When then Department of Health chief medical officer, Dr Tony Holohan, was sent by then health minister, Dr James Reilly, to Portlaoise Hospital, in 2014, he quickly produced a damning report.

It concluded that families and patients were treated in a poor and — at times — “appalling manner”, with “limited respect, kindness, courtesy, and consideration”.

Crucially, he said, “poor outcomes that could likely have been prevented were identified and known by the hospital, but not adequately and satisfactorily acted upon”.

Dr Holohan also said that maternity services could not be regarded as safe and sustainable under the governance that pertained at the time.

A 2015 Health Information and Quality Authority (Hiqa) report into the safety, quality, and standards of services provided to Portlaoise patients was also damning.

They found that Portlaoise Hospital and the HSE — at local, regional, and national level — were aware, “for many years”, of numerous patient-safety risks in the hospital, but “failed to act decisively to reduce these risks”.

Hiqa said there was “little evidence to show that appropriate measures had been put in place to decrease these risks” and noted “a widespread lack of urgency to respond to these risks”.

There were national and local reviews and investigations into Portlaoise Hospital, but the “many recommendations were not implemented in a full or timely manner — despite clear risks for patients”, Hiqa said.

Hiqa also said that it was “unacceptable” that a number of the issues it identified in its 2015 report had previously been examined in six investigations by Hiqa over seven years.

“These recurring findings indicate a basic and worrying deficit in the Irish health services: Namely, the capacity and capability to reflect on the findings of all reports, reviews, and investigations, and apply system-wide learning from these findings for the benefit of all service users.”

Hiqa said it hoped that the findings would not constitute “yet another lost opportunity for service improvement across the wider healthcare system”.

No doubt more reports and recommendations will follow if the Department of Health deems it necessary to take a closer look at Portlaoise.

Death of Ódhran Murphy

One that will need to be examined is the December 27, 2021, stillbirth of Ódhran Murphy.

His parents, Hilary and Patrick, wept at his inquest last September as they detailed how they had to bury Ódhran in two separate funerals, 11 months apart, because his organs had been removed and retained.

Hilary and Paddy Murphy were forced to bury their stillborn son in two separate funerals. File picture: Neil Michael
Hilary and Paddy Murphy were forced to bury their stillborn son in two separate funerals. File picture: Neil Michael

Their son’s inquest heard that before Mrs Murphy was admitted to Portlaoise Hospital on December 27, 2021, she had suffered pre-labour rupture of membranes (Prom) at home.

Just 19 months before, in January 2022, another Portlaoise mother — Lisa Duffy — told her son Luke’s inquest that babies were dying because “medical staff are failing to listen to mothers”.

She sobbed uncontrollably while giving evidence at the inquest into the death of Luke, who was stillborn at Portlaoise Hospital on October 29, 2018.

Ms Duffy, from Mountrath, Co Laois, told the inquest that she was suffering from increasingly severe back contractions at the end of her pregnancy, believed she was in labour, and wanted to be induced.

She was to be induced in the week leading up to October 26, 2018, but a doctor — who was not present at the inquest — insisted that she be induced instead on October 29.

Portlaoise Coroner’s Court, in Co Laois, was told that staff at the hospital did not carry out basic checks that could have confirmed whether or not the 36-year-old was in labour.

At the start of the inquest, Portlaoise Hospital’s general manager, Michael Knowles — who retired late in 2018 —apologised for the “failings of care” that “should not have happened”.

And he assured the inquest that the hospital would do “everything it can to make sure this does not happen again”.

Another 19 months previously, on May 27, 2020, the HSE had said the hospital would make sure “poor elements of care” — evident in the tragic case of Aaron Cullen — would not occur again.

Death of Aaron Cullen

Aaron died on May 9, 2016, at Dublin’s Coombe Hospital, having been born five days previously at the Midland Regional Hospital, in Portlaoise.

His parents, Claire and Keith Cullen, sued the HSE for mental distress and the case was settled at the High Court in September 2020.

The couple rejected the report on the HSE’s investigation — which began in November 2016 and was completed in March 2020 — into their son’s death.

They said it was not representative of a “full, factual and accurate account of events, or a representation of a fair and just investigation”.

The semi-anonymised report concluded: “The investigation team acknowledge that even if [Mrs Cullen’s] care had all been carried out effectively, it is accepted that this would not necessarily have changed the ultimate outcome for baby Aaron.

“But the issues identified during the course of this investigation must be rectified to ensure that they do not recur.

Claire and Keith Cullen from Co Laois leaving the inquest of their baby Aaron. Picture: Collins Courts
Claire and Keith Cullen from Co Laois leaving the inquest of their baby Aaron. Picture: Collins Courts

“The care delivered to Mrs [Cullen] and baby Aaron in [Portlaoise Hospital] is, at best, suboptimal and potentially dangerous, and such deficits would not have lessened the problems for baby Aaron.”

Unsurprisingly, when Mrs Cullen talks about what she and her husband have gone through, her grief soon turns to anger.

She is currently advising the mother of another baby who died.

It was only after Mrs Cullen got involved that the other woman learned that Portlaoise Hospital staff had conducted an investigation into her own baby’s death.

Mrs Cullen said hospital staff never informed the mother that they had carried out the investigation; that case is due to go to inquest in the coming months.

“I am aware of cases even up to this year of baby deaths in Portlaoise,” she said.

“One baby died in 2020 and another died in 2021.

“I am also aware that there are investigations into two other babies, but I do not know if there were any management or care-related issues involved.

“All the mothers I talk to tell the same story about what went wrong.

"I know of a number of parents not being told their baby’s deaths were being investigated.

“I’d love to know how many other parents have no idea how their baby died. I would never have known about what happened in our own son’s case if myself and my husband hadn’t educated ourselves on how to get around the system.

“I know of one specific, recent case where an investigation went ahead and there was a report, but none of this was disclosed to the baby’s parents until they happened to ask for an update a year after their baby died.”

She added: “It really is a case of history repeating itself at Portlaoise, but none of us can understand why there is not a full investigation — given what is happening at the hospital.

You do wonder how many babies have to die before an investigation is done on all the deaths, and preferably one done by an independent person from another jurisdiction.”

Her own son’s inquest is to be re-opened because new information, which was not disclosed by Portlaoise, will be heard.

She has learned about more cases since she set up a support and advocacy group — Safer Births Ireland — with another grieving mother, Ms Duffy.

Both of them continue to fight for answers and for change.

As this scandal rumbles on in plain sight, the list of failings at Portlaoise continues.

Despite the misinterpreted, or missed, fetal heart-beat monitoring, one key finding of an audit report in December 2022 bears mention.

The report into compliance at Portlaoise with the National Clinical Guideline for intrapartum fetal heart-rate monitoring discovered that “maternity services at MRHP had not adopted the NCG to underpin fetal heart-rate monitoring practices”.

Scandal dates back to 1997

Anybody who thinks this whole scandal just dates back to 2006 should think again.

It goes back way further — to 1997 — leading us to a 10th chair that will also be forever empty, and it is in the household of Dolores and Brendan O’Reilly.

Before a verdict of medical misadventure was recorded by the coroner in the death of their baby son, Glen, the court heard that there had been issues around fetal heart-beat monitoring. Glen should have been delivered earlier and the coroner found that fetal hypoxia was a cause of death.

While concern grows around issues raised at inquests into deaths of babies born at Portlaoise since 2013, such concern is not unique.

Research by the Irish Examiner into reports of inquests around the country points to at least 40 serious-incident baby deaths in maternity units since 2013.

 Krysia Lynch: Wants an external investigation. Picture: Moya Nolan
Krysia Lynch: Wants an external investigation. Picture: Moya Nolan

The worst year was 2018, when at least 10 babies died, but three of them died at the same Dublin hospital over a five-month period.

In at least 18 of the 40 deaths, issues around fetal heart-beat monitoring (CTG) were raised either at inquest or in the High Court.

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

As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven cases, maternity staff missed signs that a woman was in labour, hence the repeated recommendations around training.

Some 12 deaths followed a delayed delivery, while, in more than eight cases, a mother’s concerns were ignored.

The latest available figures for perinatal mortality rates (PMR) in Ireland are for 2021 and were published earlier this year.

All 19 Irish maternity units — including Portlaoise Hospital — reported anonymised data on 357 deaths, arising from 60,841 births, in 2021, of at least 500g birth weight or at least 24 weeks gestation.

As well as the 357 deaths, of which 238 were stillbirths and 119 were early neonatal deaths, there were a further 40 late neonatal deaths.

NPEC noted, in its report, that according to the National Office of Clinical Audit (Noca), no one maternity unit was considered an outlier in 2021.

The HSE was asked a number of questions, including if it had any intention of reviewing baby deaths at Portlaoise Hospital since 2013.

The agency didn’t answer that question and, instead, gave a broader comment on how it monitors and regards safety issues across all maternity units.

It said: 

The quality and safety of the maternity services is of utmost importance.

“We want to ensure the safety of all women and babies throughout the pre- and post-natal period.

“The Irish Maternity Indicator System (Imis) is an important management tool for the HSE in identifying any emerging trends in quality and safety metrics.

“Where the Imis report identifies any outlier, there is direct engagement with the relevant maternity network to understand how the variations occurred — and any corrective action that may be required.”

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