By Irishexaminer.com Neil Michael
The HSE鈥檚 determination to learn from these tragedies also does not extend to publicly acknowledging any attempt to find out what were the outcomes of all 655 baby deaths and injuries classed as Serious Reportable Events reported to the HSE鈥檚 National Incident Management System between 2016 and 2023.
No matter how many times the HSE or the Department of Health are asked, they insist there is little or no point in reviewing either of these sources of information. Last spring, this reporter was informed by a senior HSE executive that 鈥渨e know about all of these deaths鈥 鈥 so perhaps they feel they have all the answers.
But if that is the case, why are babies still dying avoidable deaths in Ireland? Perhaps the answer lies in a growing view among women that they are being gaslighted into believing they are among the main reasons for their babies’ deaths.
On the list of risk factors for stillbirths, for example, the HSE says there are congenital anomalies (birth defects) in babies and things like the age, BMI, and the socioeconomic background of mothers. It will say risk factors centre around lifestyle choices such as drinking, smoking, and taking drugs.
But what gets little attention in the panoply of health service information is the elephant in the room of Irish health services, and in particular maternity services; human error. Hardly a few months go by and another anguished mother is sobbing at the steps of either a coroner鈥檚 court or the High Court as she recounts how what happened to her baby shouldn’t have happened.
Like so many others since 2013, Lisa Duffy received an apology from the HSE for care failings. She was promised that lessons would be learned. The apology came at her son Luke鈥檚 inquest in January 2022, which resulted in a verdict of medical misadventure.
Luke was stillborn in 2018 at Portlaoise Hospital, after 鈥 among other things 鈥 midwives failed to spot that Lisa was in labour. Since experiencing Baby Luke鈥檚 鈥渘eedless loss鈥, she has been at the forefront of maternity reform advocacy.
鈥淵ou don鈥檛 realise the extent to which things can go wrong despite you and your baby being perfectly fit and healthy,鈥 she recalls. 鈥淵ou also just take it for granted that you will be cared for and trained staff will do their jobs properly.
鈥淏ut bitter experience has shown me and so many other mums and dads that you can take nothing for granted. They will tell you there are lifestyle factors and there are these congenital anomalies but what they won鈥檛 talk about in any great detail are the mistakes that get made.
Women are gaslighted into believing the main reasons are themselves or their babies.
鈥淵et, as I and so many others have discovered, human error is also a big cause not just of avoidable baby deaths but also birth injuries.鈥
It was Lisa’s help with Irish Examiner-initiated research in 2023 that led to the discovery that there have been at least 56 avoidable baby deaths in maternity units in less than a decade.
Cardiotocography (CTG) monitoring
The research, based on a review of reports of inquests into babies who died between 2013 and 2022, led to calls for a review of avoidable baby death.
The research threw up a number of factors common to cases, such as delayed deliveries, a lack of appropriate training and communications failures by staff.
The biggest single factor in 28 of the 56 deaths was related to cardiotocography (CTG) monitoring of babies鈥 hearts and the mothers鈥 contractions.
On December 21, 2023, the then health minister denied in an RT脡 interview that there was any 鈥渢rend鈥 in relation to CTG playing a factor in baby deaths.
Stephen Donnelly鈥檚 response came weeks after the State Claims Agency itself stated, in a review of ‘Catastrophic Claims relating to Babies in Maternity Services’, that issues around CTG had indeed played a major factor in claims.
In its review of 80 catastrophic claims concluded between 2015 and 2019, it noted health staff 鈥渇ailed to interpret or recognise鈥 abnormal CTG trace results in more than 60% of claims over the five-year period.
Rise in baby deaths
Research, again by the Irish Examiner, has discovered there have been five times more baby deaths and baby birth-related injuries reported to the HSE in 2023 compared to 2016.
The figures, released under Freedom of Information legislation, relate solely to near-term and term babies weighing more than 2,500g or 5.5lbs.
In total, there were 655 Serious Reportable Events (SREs) involving babies reported to the HSE between 2016 and 2023.
But the agency can鈥檛 say how many of the 655 baby deaths and birth injuries reported to its National Incident Management System resulted in a negative outcome. This is because they don鈥檛 collate the information centrally.
Instead they say each hospital is left with primary responsibility 鈥 鈥渁nd accountability鈥 鈥 for the effective management of incidents.
Indeed, if you ask them why they can鈥檛 just ask each hospital what the outcomes were, the HSE will insist that it is not as simple as 鈥渟ending around a few emails鈥.
Instead of going back over the SRE reports, the HSE instead launched a new initiative that will take years to complete.
This is the confidential inquiry the National Women and Infants Health Programme (NWIHP) launched last year into data about still and newborn baby deaths between 2021 and 2023.
Cases to be examined have been identified from existing perinatal death audit data from the National Perinatal Epidemiology Centre (NPEC), based in Cork.
When asked why a new process was started instead of studying the outcomes of 655 baby deaths and baby injury related SREs, the message was the same; it’s just not that simple.
England has a huge problem with preventable deaths, with a parliamentary report in 2021 openly acknowledging thousands of babies die preventable deaths in NHS maternity units every year.
Is it not time for the Irish health service to do the same? Or is it just not that simple?