Dáil Éireann debate -
Thursday, 14 Jun 2018

Vol. 970 No. 3

Independent Clinical Review of Maternity Services at Portiuncula University Hospital: Statements

Minister for Health (Deputy Simon Harris)

I welcome the opportunity to update the House on the Portiuncula University Hospital Health Service Executive, HSE, review of the maternity services and of a known number of adverse events between 2008 and November 2014, also known as the Walker report.

I would like to begin by expressing my deepest sympathies to the families involved and welcome the completion of this review for them. I also thank them for their engagement in the review process, which was so important. The review was carried out by an external clinical review team led by Professor Walker. The learning from this review will help with the development and delivery of maternity services in the future.

The Walker report has two parts. First, it provides a review of the maternity service provided by Portiuncula University Hospital, which is part of the Saolta University Health Care Group. Second, it reviews the care 18 babies and their mothers received and presents the overall findings from across these cases.

I wish to recall what happened in Portiuncula University Hospital, how the issues came to light and how my Department and the HSE responded. Portiuncula University Hospital provides maternity services alongside general hospital services. It is a model 3 hospital providing 24-7 acute surgery, acute medicine, critical care, emergency department and maternity services. In 2017, there were 1,668 births. The maternity department comprises 33 beds and four delivery suites.

In 2014, six babies were referred from the hospital for therapeutic hypothermia, also known as head cooling. This is used to try to reduce adverse effects from a lack of oxygen to a baby’s brain at the time of delivery. The hospital considered that six babies being referred for head cooling was higher than expected and, in November 2014, a preliminary review of these cases was undertaken by the hospital. This preliminary review found a cause for concern in the management of labour in some cases. As an immediate action, Portiuncula University Hospital agreed, and put in place, corrective actions and protective measures, including a process for the ongoing monitoring of all deliveries. The hospital undertook an audit the following month, in December 2014. This was to assess whether the recent changes were effective. The audit confirmed that all protective measures had been fully implemented and provided assurance that the services in place were safe.

Following the preliminary review, an external review was commissioned by the Saolta University Health Care Group in February 2015. The purpose of the review was to provide a general review on maternity services and to consider the care provided in the individual cases. The external review team was set up to operate to a number of terms of reference. These terms provided for a review of the maternity services in general and a review of the individual cases. In early 2015, an expert review team of seven members was established. This was chaired by Professor James Walker, professor of obstetrics and gynaecology from the University of Leeds. The membership comprised two obstetricians, two midwives, two neonatologists and a patient advocate.

At the commencement of the review the external team established a patient helpline for families who may have had concerns about their care. As a result of this, an additional 12 cases involving ten families were identified. In addition to the six babies covered by the preliminary review, the final external review covers the care provided to 18 babies and 16 families. I am assured that throughout the review process the HSE communicated with and met families and offered any services that they required to support them in dealing with the issues that arose. The review commenced in April 2015 and each case had an individual systems analysis conducted to identify the care received. These individual reports were provided to the families in April 2017.

I turn to the report's findings. I wish to extend my sincere sympathies and thoughts again to the families impacted. I thank them sincerely for coming forward, sharing their experiences and inputting to the review. By outlining those experiences, bringing their stories forward and demanding change, they have helped us to try to improve our maternity services, leading to the improvements that have been put in place. The clinical review team found that of the 18 cases reviewed, serious errors in management occurred in ten. The team considered that if those errors had not occurred, there would probably have been different outcomes for those babies. To recognise the trauma and hurt for the families, I will record for the Dáil the outcome for the babies involved. There were three stillbirths, three baby deaths, two babies with developmental delays, four babies who have ongoing issues and six babies who are considered to be doing well.

We cannot underestimate the extent of the impact of these events on the families, relatives and communities involved. It is important that the learning from the report and the experiences of these families should be a driver for change across all our maternity services in order that we can improve the experience of women and families as we go forward with our maternity services. To distil the learning, the report identifies a number of causal and contributory factors which affected the care received. The findings encompass a number of key areas, including lack of appropriate staffing, training across the multidisciplinary team, provision of clinical care, slow recognition of maternity incidents, communications with families, lack of open disclosure and lack of bereavement supports.

Important recommendations were made and I will outline some of them to the House. There were 35 key recommendations in total and the HSE has been asked to address them as a matter of priority. The recommendations include changes related to the care environment, training, provision of clinical care, staffing and improvements needed to deal with communication. The report outlines the need for the maternity services to respond to increasingly diverse and complex population needs to provide safe, evidence-based, accessible care to all women, babies and their families. It also highlights the need for maternity networks supported by effective leadership, management and governance arrangements. These are recommended to share expertise across maternity services. Data collection and use of information to detect patterns and ensure ongoing review of care provided are highlighted. Recommendations are made on the changes to how maternity services are staffed, the skill mix used and priority areas for training in order that maternity services can respond to increasingly diverse and complex population needs to provide safe, evidence-based, accessible care to all women, babies and their families.

We clearly need action on foot of this review. I have been advised that Portiuncula University Hospital has an implementation team in place to progress the recommendations and that most of the actions have been implemented. I thank the local team that has been working on this. Local Deputies will be aware of the work that has been ongoing to ensure the recommendations are implemented. Some of the key changes at the hospital include additional staff and a number of senior appointments. A director and assistant director of midwifery were appointed in 2016 and the number of consultants has increased to five from three. In addition, I am advised that training on open disclosure, CTG reading and relevant clinical issues has taken place in the hospital. I particularly welcome the fact that the implementation team includes input from some of the families affected. The implementation team must involve the families to drive the changes. That is important to ensure the findings of the review translate into meaningful improvements in care as experienced by the patients in the service.

Finally, I refer to the ongoing work being undertaken at national level to facilitate the provision of a consistently safe and high quality maternity service. Ireland's first national maternity strategy was published in 2016. It is incredible we did not have such a strategy until 2016. That probably gives us an insight into how maternity services were, perhaps, the Cinderella of our heath service. I am pleased that the previous Government delivered the first strategy. It is important and it enjoys widespread support across the House. However, it is no good having a strategy if there is no forum in which to implement it. The HSE national women and infants health programme was established in 2017. The programme is entirely dedicated to women and infant health care, delivering the national maternity strategy and driving improvements in maternity services nationally. The programme has published its implementation plan and is currently overseeing the establishment of maternity networks, an issue that arises in the Walker report, in all hospital groups.

Lessons have been learned from a difficult period in our maternity services, and the lessons that need to be learned have been identified. A number of changes have taken place in Portiuncula University Hospital, as I outlined earlier, but clearly the lessons from there must also be learned at national level. It must be about delivering the national maternity strategy and applying the lessons across the health service in terms of staffing levels, training for staff and the development of the maternity networks. Today's debate is a timely opportunity to reflect on the progress that has been made to date and to note the further steps that must be taken.

Deputy Stephen S. Donnelly

On behalf of Fianna Fáil, I wish to extend our thoughts to the mothers, fathers and babies at the centre of the Portiuncula University Hospital report. What the report highlights is truly outrageous and scandalous. The report on maternity services at Portiuncula University Hospital was released approximately two months ago. It did not get much attention because we were in the middle of the CervicalCheck scandal and a campaign to repeal the eighth amendment. The report lays out a scandalous series of failures in respect of mothers, fathers and babies by the State. The bitter irony is that the report on this scandal relating to women's reproductive health did not get much attention when it emerged because we were preoccupied with two other issues relating to women's reproductive health.

By and large, we have great maternity care in Ireland. We have one of the lowest maternal death rates in the world thanks to the fantastic work every day of our doctors, nurses, midwives and everyone else involved. When it comes to women’s health and the control of women’s bodies, however, this State has a dark past - the Magdalen laundries, mother and baby homes, symphysiotomy, forced adoptions and falsified birth certificates. The list goes on and on. Now added to that list is what happened at Portiuncula hospital between 2008 and 2014 and who knows when else at that hospital.

A total of 18 births were examined. Six involved either stillbirths or the death of the baby shortly after delivery. Six of the babies who survived suffered injuries leading to lifelong disabilities. A litany of errors led to the serious harm and deaths of those babies. The report found that in ten of the 18 cases there was a relationship between errors made and the outcomes for the health and lives of those children.

What happened? The report found there were insufficient resources, insufficient weekend cover, with sometimes no obstetrician and no midwife at the weekends and out of hours - so who was delivering the babies? -insufficient leadership, insufficient management and quality control, the wrong staff at the wrong times, the wrong training, the wrong qualifications and the wrong layout of the hospital. The list goes on. The report concludes that all of these errors combined to lead to the serious harm and death of babies. That serious harm was preventable. Sadly and soberly, those deaths were also preventable.

After all of this came the failure to investigate; the failure to tell parents that mistakes were made; the failure to tell parents about coroner reports and investigations; the failure to tell parents that a review was even taking place; the failure to inform the Minister for Health; and the repeated failure to apologise.

RTE’s "RTÉ Investigates" told the story of just one such family, whose two baby girls died in Portiuncula hospital. A review of one of the deaths took place in 2011. The parents were never told about the review, nor were they included in it. They found out about the review on television years later. When they found out, they applied for information under data protection legislation and what they discovered was damning. It included, for example, one email from a person at the hospital saying: “Obviously, I am concerned that the coroner’s directive to carry out a review will be discoverable.” That is a cover up. That is what happened. In 17 of the 18 cases the report found a lack of disclosure.

We welcome the recommendations and we welcome the Minister's list of things that have improved, but it is not enough. I am asking the Minister to come back with a comprehensive document listing every recommendation in this report and stating what has happened to date, which recommendations have or have not been completed and a timeline for when that will happen.

Deputy Eugene Murphy

I will share the rest of the time with Deputy Rabbitte. I thank both Deputy Donnelly and Deputy Rabbitte for sharing time with me.

A shocking litany of failures and errors is outlined in this long-awaited report of an independent review of maternity services at Portiuncula hospital in County Galway. Of the 18 maternity cases which were reviewed, six babies died and in ten cases there were there serious errors of management that would probably have made a difference to the outcome for babies. As Deputy Donnelly said, it is important that we remember this evening the babies who died and their families, and acknowledge the horrific heartbreak and trauma which the families have endured and no doubt are still suffering as they come to terms with such huge loss.

The report highlights a number of key issues relating to the service provided in Portiuncula hospital between 2008 and 2014. These include delays in escalation of concerns to more senior decision-makers, deficits in both medical and nursing staff numbers, poor CTG trace interpretation, and concerns relating to the administration of oxytocin during labour. The report raised concerns over the communication with families during and after their time in hospital. The report also highlighted historical issues relating to the governance structures in place between the hospital and the group at that time.

The report made 154 recommendations under five headings. I know the Minister said that most of those had been put in place, but I would like him to inform us as quickly as possible which have not been implemented yet. These families have suffered the greatest of all losses, the loss of a child. That serious errors of management would probably have made a difference to the outcome for some babies in some cases compounds the tragedy. While nothing can ever compensate for the loss of a child, the State has an obligation to these families to ensure that all of the key recommendations on maternity services at Portiuncula hospital are implemented to ensure that no other mother or father has to suffer the same heartbreak. That is the very least we owe them.

Deputy Anne Rabbitte

I thank my colleagues for sharing their time with me. I had my baby in 2005 and was fortunate. I gave birth in Portiuncula hospital and had a very good experience. It is important to put that on the record at the outset. I attended the briefing session in Ballinasloe on the night it was announced. Maybe I am cynical, but the strategic release with only 24 hours' notice to coincide with the CervicalCheck scandal meant minimal media coverage and that it flew under the radar. It was a cynical move by HSE at a time when people were at saturation point when it comes to national scandals and the failings of our health system. It is another shocking example of the failings of HSE when it comes to perinatal care and health of Irish women.

The key findings from the investigation of 18 cases that occurred from 2008 to 2014 were as follows. Sixteen families have suffered greatly, including one family that lost two babies. Six babies have died. Of the 18 cases examined, serious errors occurred in ten cases which would probably have made a difference for the babies involved.

The lengthy report included more than 150 recommendations - too many to mention here. Not least was the lack of clinical governance and proper incident management. The main issues were problems in clinical care and problems with communication after delivery. For most people attending hospital, clinical care was adequate provided nothing went wrong. This is setting the bar far too low, hoping that everything will be all right because if it is not, who knows what could happen.

Inadequacies were found in staff ability to interpret abnormal test results and to respond appropriately, escalate care level when needed, make timely clinical decisions, and communicate effectively among themselves about women and babies in their care. Surely these are basic skills. The lack of communication among medical and nursing staff on the ground is indicative of a hierarchical structure in which those higher up cannot be questioned. It is frightening that problems with staff communication after delivery are similar to problems with CervicalCheck. Information was not given to women and their partners in an appropriate or timely way. It is clear that this is not a one-off for the HSE but rather something that happens routinely.

In only 20% of cases was communication to parents about what had happened to their baby deemed satisfactory. Most women felt that they were not listened to before or during labour, that their concerns were dismissed by staff, and that no one explained how unwell their babies were and why. There was no chance to debrief about what had happened. Women did not understand why particular tests and procedures were being carried out. If people do not understand what tests are about, how can they give informed consent? Technically, to proceed without consent is a criminal offence. It was generally felt that there was a lack of openness. This seems to be a common theme across HSE with no open disclosure and no informed consent. How much hurt could have been avoided by open communication? What else are we not being told?

Many of the key recommendations are basics and would be standard practice, including clinical handover, staffing ratios, proper induction of new staff, appropriate leadership, the presence of senior staff on wards, and following best practice guidelines. I know I am out of time, but on the night of the presentation, I was there flicking through the report, as anyone else would do. What stood out for me was the lack of appropriate midwifery-led care either in the clinics or on the labour ward. In two cases when appointing the senior midwifery staff member, she was not qualified as a midwife. That is unbelievable in a maternity hospital.

Pat Nash described the situation in Ballinasloe that evening.

Nurses were not talking to each other, the level of communication was bad and personal issues were getting in the way and affecting how decisions were being made.

Deputy Martin Kenny

I offer my sympathies to all those women and families affected by the serious and scandalous errors which occurred at Portiuncula University Hospital and resulted in their babies dying or being left with life-changing injuries and disabilities. I thank Professor James Walker who led the expert review team and authored this report. While the report into what happened in the care of these 18 babies was much needed, it is a shame that such errors and poor care occurred in the first instance. As in the case of the report into baby deaths at Portlaoise hospital, this report highlights huge failures, some of which continue to exist in our health service. Historically, maternity care has often been underfunded, subject to poor medical practices and has been investigated continually as a result of neonatal and maternal deaths and injury.

Reports such as this report into Portiuncula hospital do not exist in isolation. They follow a pattern of poor care for women and infants in this State. It is not lost on the women of this State that not only do they receive inadequate maternity care, but even where care is given, there are significant problems due to understaffing, poor practices, inadequate equipment and a health service that is not sensitive to, and does not reflect, gender differences. In other hospitals, a 20-week scan is not standard procedure. This is a huge problem across many of our maternity hospitals.

The report criticises the hospital for poor communication among maternity staff and a lack of skills and training to deal with emergency cases. It found that there was a general lack of skills and training among front-line staff and a lack of obstetric consultant supervision in the labour ward. It also found that consultants appeared to wait to be called and did not take ownership of the clinical care being given, and this resulted in an inappropriate handover of care. The report also found that care when things were progressing normally appeared to be of a high standard but the response to a deteriorating situation was often slow and deficient. This appears to a trend across many of our maternity hospitals and general health services.

When one delves into the report and reads the testimony of those interviewed, one gets a feel for a hospital that was being neglected by management and plagued by difficulties in recruiting and retaining staff. During interviews, the obstetric consultants at Portiuncula hospital expressed to the critical review team their concern that the level of training and experience of some of the non-consultant hospital doctors, NCHDs, was not of a standard previously seen and that this was significantly compounded by the fact that there was an unfilled registrar training post in Portiuncula University Hospital, PUH, and that junior grades were often filled by locum doctors to cover registrar positions. Yesterday, Sinn Féin received a response to a parliamentary question from the HSE, showing that Portiuncula hospital spent €5.6 million on agency staff in 2017. This is reflective of a crisis in recruiting and retaining staff.

The result of the above problems at PUH was that doctors came with different levels of knowledge and varied knowledge of the Irish maternity system. The clinical review team, CRT, was also informed that there were no formal clinical assessments of new appointees and no increase in supervision by consultants as there were only three consultants to run the service. The CRT heard a lot of concerns from the midwifery staff, who felt generally unsupported and that the midwifery management structure was fragmented. The midwifery lines of responsibility were very convoluted and midwifery staff levels were deficient, with a lack of consistent CMM cover in the labour ward. Midwives had requested more staff as early as 2013. As a result of these staffing deficits, there was a lack of support for junior midwives, and midwives said they sometimes found it difficult to escalate to an obstetric consultant.

The report found that in many instances systems failures, staff deficiencies, poor practices, a lack of training and skills among staff, particularly agency staff, and poor management and oversight played a significant role in the errors that occurred, which resulted in baby deaths or babies being left with life-changing injuries and disabilities. Such failings go to the heart of the problems and crises affecting the health service. Among the issues highlighted in this report are a recruitment and retention crisis, an underfunding of our maternity services, an over-reliance on agency staff, and a lack of appetite to implement the national maternity strategy and bring Ireland into line with Birthrate Plus standards and so on.

Another issue pointed to in the report was a lack of open disclosure of information to the family, an issue arising in so many other areas of our health services, as dealt with in this House in recent days. Even when information was provided, some of it was withheld and families told the CRT said that they only received information regarding events during delivery a significant time after the baby's birth, often weeks, months or years later. The CRT acknowledged that it is incredibly frustrating for families not to get important information about their cases in an open, transparent and timely manner. Time and again, such issues have arisen in our health service, including in the recent CervicalCheck scandal. My colleague, Deputy Louise O’Reilly, who cannot be here due to an engagement with survivors of the transvaginal mesh scandal, introduced a Bill earlier today to make open disclosure mandatory, not voluntary. This is a critical issue. The problems and hurt a lack of open disclosure have caused to the women and families affected cannot be overstated.

The recommendations contained in this report and the national maternity strategy must be implemented as a matter of urgency. If these recommendations are not implemented and if the individuals and agencies do not take responsibility for what happened, these scandals will continue. There should automatically be an inquest into every maternal death, neonatal death or death of a baby during delivery. Deputy Clare Daly’s Coroners Bill provides for automatic inquests in all cases of maternal deaths in our hospitals. The Government refuses to progress this Bill. We need to see such legislation enacted as a matter of urgency.

I again offer my sympathy and the sympathy of Sinn Féin to the women, families and babies affected by this scandal.

Deputy Alan Kelly

I welcome the publication of the clinical review of the maternity services as Portiuncula hospital and this opportunity to discuss its findings. I commend the families who came forward, some of whom I know and have met. They are very brave. They are not happy with this report and they propose to continue the fight because they do not believe it goes far enough in terms of addressing the appalling experiences many of them had at the hospital. Like everyone else, I extend my sympathies to the families and extended families affected by this scandal. Following on from this report, lessons must be learned.

This report is a damning indictment of the manner in which we have treated women in this country. Publication of this report went below the radar because of the time at which it was published. I share Deputies' concerns in this regard. This report was long delayed. I met the families who told me they had seen the preliminary version, and although they were not happy with it, they knew it was ready to be published. This report was published at the time of the referendum and the CervicalCheck scandal, so it did not get the attention it deserved. The Minister might want to explain why that happened because people are coming up with their own answers as to why it happened.

I have spoken to the families affected and they are not happy with some of the report, though they accept other parts of it. No amount of apologies from the Saolta University Health Care Group will be of any comfort to them because the State let them down. It let down people who are very vulnerable and who suffered. One of the families, which I will call "D and C" and with whom I have had communications on a number of occasions, feels the review was inefficient. They said they would like to highlight the lack of efficiency in the review, question the method and independence of it and question the group, particularly as much of what was going on at times reached the media before it reached them.

The report was due originally in the summer of 2015 and has taken almost three and a half years to complete. This has added enormous suffering to an already traumatic experience and it is unacceptable. The hospital group had many questions to answer in the time leading up to the report being compiled. At the time, however, it seemed more concerned about its public relations profile than the families at the centre of this, something which, I contend, mirrors what is happening with CervicalCheck at present. A lengthy list of the failures in the delivery of maternity services at PUH has been published. It makes for quite difficult reading. Serious errors of management occurred in ten cases that would have led to different outcomes. There was a lack of management, and the process relating thereto, and leadership.

In 2014, six babies were referred from the hospital for therapeutic hypothermia, which was considered a higher figure than average at the time. Therapeutic hypothermia, or targeted temperature management, TTM, is a treatment whereby body temperature is maintained at a specific level in order to improve outcomes following a period of reduced or stopped blood flow to the brain. Following this, there were an additional 12 cases and we know what happened as a result. The report represents a catastrophic failing and falls in line with other failures. I have a very important question for the Minister. The review has a specific timeframe but these issues did not appear out of nowhere. I know people who believe that there are issues in this hospital dating from before this timeframe which need to be reviewed. Will they be considered?

I will focus on a number of key points in what is a very detailed report. The clinical review team noted that a shortage in staff numbers, limited access to training and limited availability of resources impacted upon the ability of PUH to keep up to date with some of the latest developments in skills and techniques in clinical care. The clinical review team also noted, from interviews relating to the 18 system analysis investigations, SAIs, and PUH training records, that the experience, level of ability and training of some obstetric non-consultant hospital doctors was not at a level previously experienced, requiring greater senior support.

We are acutely aware of the ongoing crisis management in respect of staffing at the hospital and across Ireland. We discussed this recently in the context of the number not on the specialist register who have been appointed to consultant posts. What happened in the case of Portiuncula also happened in the past, which shows where we are heading in respect of problems in the future. Such problems will be on a mass scale across many disciplines. If we are appointing people who are not qualified to take up roles and who do not have the experience, training or knowledge of dealing with cases, we all know where that will lead, not just in obstetrics but also in other areas.

The report is shocking and deeply worrying. Given that the hospital was aware of its shortage of staff, it is baffling that there was no autonomous midwifery to take on low-risk care independently. This could have taken the form of clinics, led by midwives, in intrapartum care in order to allow doctors to focus on cases where there was significant medical need. There was also a clear breakdown in organisational terms. It is nothing new to us to hear of the HSE breaking down in organisational terms. In 2008, the hospital was a stand-alone operation under the umbrella of HSE west and then became part of the group it is in now. The review is very critical of this, stating:

... senior staff at PUH did not feel involved and believed that they no longer had ownership of their environment. It is the view of the CRT that this may have contributed to PUH being less able to respond to the problems that arose at a local level. At the time of the 2014 cases, incidents were reported onto Q-Pulse initially by PUH staff. Preliminary Assessment Reports (“PAR”) were completed by PUH and forwarded to the Serious Incident Management Team “SIMT” meeting. There was no further action after the escalation of the first two cases

Why was this? It was because the structures of the HSE did not allow it and there was nowhere to go. This represents the complete systemic failure of an organisation.

It is extremely difficult to read all the clinical issues identified in the report. I welcome a number of recommendations relating to the care environment, training, clinical care, staffing improvements, the need for effective leadership, change in governance arrangements and data collection. We all know that open disclosure did not happen but there have been key changes, with additional staff in the form of a director and assistant director of midwifery and an increase in the number of consultants to five. However, we need to ensure that this report is implemented. We also need to ensure that, where there are other cases, they will be dealt with independently.

We also need to learn from this on a number of fronts. We have a national maternity strategy which, even as Opposition spokesman, I would say is brilliant but it is not being funded. A new hospital is required in Limerick but it cannot even get a couple of million euro for it to start. There are issues over neonatal brain injury rates. Are voluntary hospitals sharing their neonatal brain injury data with the HSE? Are there any outliers that we need to be concerned about? Evidence which has been sent to me suggests that there may be. Is there any resistance to data-sharing in this area? Does the national women and infants health programme have sufficient authority to oversee outcomes on behalf of the Department of Health? Are voluntary hospitals dealing with outcomes appropriately?

It would be wrong not to mention the correlation between the recommendations in this report and the Bill I introduced in the House yesterday. The Civil Liability (Amendment) Bill 2018 is a critical small piece of legislation based on the death of Conor Underwood, the son of Derek and Mignon Underwood, in Wexford General Hospital. Where a stillborn birth occurs, there is not the capacity for the family involved to seek redress. This is an anomaly and, in the context of the issues identified in this hospital, I ask the Minister to co-operate with the Department of Justice and Equality to ensure that it can be speedily added to another Bill.

Deputy Mick Barry

First, I thank the families affected who came forward with their concerns about maternity hospital services at PUH. I express to them the condolences of the Solidarity-People Before Profit group.

The manner in which this State has treated women and children has been both a recurring theme and a major issue for Irish society. Indeed, the recent referendum was part of the overall debate within society about these matters. The neglect of women and children in the 20th century is becoming better known.

The House has just discussed the situation facing those who were adopted and whose births were registered illegally. This State has a shameful record when it comes to mother and baby homes and industrial schools. The matter we are discussing, however, relates to maternity services in this century, not the distant past. There are people in this House who have been members of Cabinet at various points during the period in question. The recurring theme of neglect of pregnant women and children has continued into this century.

The review identified 18 cases between 2008 and 2014. A number of children died and those that did not die suffered serious conditions such as brain damage and cerebral palsy. The children and their parents are facing that situation. Births, of course, are not without risk. However, this report identifies factors in these cases that could have been avoided. Proper practice and resources would have avoided the negative outcomes. The report identifies that different management of obstetric care would have resulted in better outcomes for the children in ten of the 18 cases involved.

The report is clear about the issues at Portiuncula. There were clear failings in the escalation of concerns. Staff numbers were not sufficient to meet the needs of mothers and children. There was a clear lack of staffing at weekends and out of hours. The relevant consultant or midwife was not on duty on several occasions. There were also issues with training and practices when there were difficult births. The lack of use of oxytocin is mentioned as well.

Families were not openly communicated with and this intensified their grief. There are two examples of bereaved parents being contacted about their children by staff members at the hospital who were not aware that those children had died. This did not happen in the distant past, it was the practice here recently. What was the Ireland of 2008 to 2014 like? It was the era of austerity. Public services were cut back massively. Political decisions were made to prioritise the bank bailout and to make workers and public services pay for that bailout. We had severe reductions in public services, including the health service.

Those in government at the time were austerity Ministers. Budgets were slashed and burned. Political decisions have a real effect when they reduce budgets. We have a ballooning waiting list in our public health service, with hundreds of thousands of people awaiting various procedures. Cuts to public spending mean fewer staff in our hospitals at times when they are needed. Anyone visiting a hospital knows the dedication and professionalism of healthcare workers. What happened at Portiuncula was that there was a lack of training, resources and staff to serve the needs of women and newborn children.

Deputy Clare Daly

The release of this report came at the height of the CervicalCheck scandal and it landed with less impact than it deserved. The CervicalCheck scandal hit the headlines. It was, unfortunately, an opportunity for some politicians, who may have been asleep at the wheel regarding this issue for the past ten years, to get a few headlines for themselves by shouting and roaring. They woke up and realised that there are deep-seated problems in the HSE with respect to owning up to and learning from mistakes. It is unfortunate that the news cycle can only fit in one scandal at a time. Perhaps we can learn from that. It is important that we talk about the import of the Portiuncula report. I am sick of talking about the catastrophic failures in our maternity services. I refer to the failure to admit mistakes which gives rise to the failure to learn from them. That leads to catastrophic harm to women and their babies followed by delay, cover-up, denial and the whole brutal cycle starting all over again. More than anything else, that is what strikes me about this report.

The report was released three years late. It was so late that Warren and Lorraine Reilly, the parents of two of the babies that died in Portiuncula, Asha in 2008 and Amber in 2010, initiated legal proceedings because of the delay. We should say that Mr. Warren Reilly said he and his wife had never intended taking legal action. They thought that the review, which started in January 2015, would give them the answers they sought. It was, however, repeatedly delayed. They had no option but to take on a solicitor to try to get the answers that they desperately wanted and deserved. This is what happens in so many cases. People want answers; that is all they want. They are forced into court when they find the door slammed in their faces and then experience all of the trauma, stress and expense involved in getting those answers.

It is wholly unacceptable and we, as a society, have to address it. There is no doubt that serious failures are outlined in the Portiuncula report. Those failures led to or contributed to the deaths of six babies and injuries to six others. These major failures, which obviously had catastrophic outcomes for the babies, the women and for the families, should not come as a surprise to anyone. Although we constantly hear about the excellent quality of our maternity services, the sad fact is that there were 31 inquests into baby deaths in the Republic of Ireland in the ten years between 2007 and 2017. In June 2016, the investigation of baby deaths at Portiuncula hospital was only one of many. Of our 19 maternity units, seven at that time were either under independent investigation or involved in inquests. That is a shocking statistic. The story of Portiuncula is the same as it has been everywhere else for the families involved. In addition to their dreadful sense of loss, they have had to cope with the overwhelming stress of trying to get answers from frightened hospital staff and an intransigent HSE.

I will give one example. The inquest relating to baby Amber Reilly, who died in 2010, was held in 2011. The Dublin coroner, Dr. Brian Farrell, wrote to Portiuncula hospital asking for a full review of its maternity services to be carried out. In early 2015, Amber's father, Warren, said that the family had never been contacted about the review and had no idea if it ever happened. That is unbelievable. In February 2015, the Saolta University Health Care Group announced a review following the deaths of two other babies. It said that the review would cover a nine-month period in 2014. The Reillys only learned of this review via the radio. They realised at once that it was not going to cover the deaths of their two babies, Asha and Amber, both of whom died in Portiuncula.

The Reillys were like so many families in this State. Mark and Roísín Molloy are struggling to get the truth about the death of their baby, Mark, in the Midland Regional Hospital in Portlaoise. The Reillys had to go public before the cases of their babies were taken into account. How utterly shocking is that? They only learned in 2015 - after the second review was announced - that a review of Amber's death had actually taken place in 2011 and that recommendations had been made. Even worse, those recommendations had not been followed through at that time. That is appalling. After the 2011 review was completed, a doctor at Portiuncula hospital wrote to the State Claims Agency about sending a copy of the review to the Reillys. He wrote that he did not see any place in the correspondence with the coroner where a copy of the report was required to be given to the parents of a deceased baby.