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Staff failed to recognise signs of foetal distress in baby who died at 22 minutes old

The HSE has apologised to the baby’s parents.

Mark and Roisin Molloy, parents of baby Mark
Mark and Roisin Molloy, parents of baby Mark
Image: Leah Farrell

THE HSE HAS apologised to the parents of a baby who died at a Portlaoise hospital, saying that “significant failings” were identified in a review of the circumstances of his death.

Baby Mark Molloy died 22 minutes after his birth in January 2012 at Midland Regional Hospital in Portlaoise. An RTÉ Investigations Unit report last year highlighted the deaths of five babies at the hospital during a six-year period up to 2012.

Following the report, HIQA carried out an investigation into Midland Regional Hospital. The report found repeated failures and non-compliance in National Healthcare Standards by both the hospital and the HSE.

In May of this year, Health Minister Leo Varadkar said that some services at the hospital will be discontinued.

Parents Mark and Roisin Molloy had called for an inquiry following the death of their baby, Mark.

Now the HSE has published a report – at the request of baby Mark Molloy’s parents, and with their permission – following a Systems Analysis Review into the death of Mark.

The Molloy family has also requested that baby Mark’s Cardiotocography (CTG) trace be published.

The HSE said:

The report identifies a number of significant failings into the death of baby Mark. The HSE reiterates its unreserved apology to the Molloy family for these failings and the distress and anguish caused to them.

These reports are not typically published, and the HSE acknowledged “the courage of the Molloy family for their consenting to the publication of this report”.

Findings of the report

19/5/2015 Babies Deaths in Portlaoise L TO R. Mark and Roisin Molloy, Ollie Kelly and Amy Delehunt will address the session of the Health Committee meeting into the babies deaths in Portlaoise Hospital. Source: Leah Farrell

Today’s HSE report identified two ‘care delivery issues’ related to the care and management delivered to Roisin Molloy and her son Mark.

These were:

  • Failure to recognise and act on the signs of foetal distress.
  • Failure to fully assess all sections of the CTG resulting in a) the inappropriate prescribing and administration of Syntocinon and b) a delay in the decision to transfer Mrs. Molloy to the Theatre Department for an assisted delivery.

It found that there was evidence that the baby was showing signs of foetal distress from 6.30am and that at that time assistance should have been sought from the obstetric gynaecology clinical team on duty. However, these signs were not identified and acted upon.

The investigation also found that:

…when Mrs Molloy was assessed by the Obstetric Gynaecology Registrar at 07.55 hours that all sections of the CTG trace were not inspected and assessed at that time and that therefore the earlier decelerations ie that had occurred between 06.33 hours and 07.15 hours and at 07.45 hours were not identified which led to the decision to inappropriately prescribe and administer Syntocinon.

The report looks into the factors that contributed to these issues, and made a number of recommendations as a result.

These include the development and implementation of a guideline related to providing mementoes – like a lock of a baby’s hair, or a footprint – to parents following a baby’s death. They should also give information to parents about stillborn and neonatal death organisations.

The birth

The report states it was documented that while Roisin Molloy was walking to the labour ward, she had two contractions. She said that the midwife did not come back up to stand beside her and provide support, but stated “I’ll wait for you here” as she was nine metres ahead of them.

Roisin Molloy had requested an epidural, but said that when she requested it again at the labour ward, the same midwife as above stated “it is not my job to call an anaesthetist”.

The Molloys said that they found the number of staff entering and leaving the room while Roisin Molloy was in labour to be distressing, as she was in a “vulnerable and exposed position”.

They also documented that they had no idea that their infant son was in trouble prior to his birth. They said that as he was delivered, they were expecting a healthy baby.

When he was born they were both “thrilled” and Mr Molloy told Mrs Molloy “it’s a boy”. Roisin Molloy said she had a very clear image of Mark running after his older brothers wearing a pair of red wellington boots.

The birth was initially classified as a still birth, but this was later changed to ‘alive birth’ as a consultant anaesthetist confirmed that the baby might have had a heartbeat when he was born.

The first time the parents were aware that baby Mark was ill was around 10 minutes after his birth, when the consultant obstetrician gynaecologist indicated to them that ‘things behind me do not sound good’. The baby was being resuscitated.

After the baby’s death, Roisin Molloy said a midwife gave them a document which had a memory booklet with a lock of hair and hand and foot prints, but also information on breastfeeding.

The parents said they were surprised and upset to hear baby Mark would be transported by taxi for his post-mortem. Mr Molloy held him in the taxi en route to the mortuary.

Improving standards 

The HSE said that the findings of this report and its 43 recommendations have been implemented in the maternity services in Portlaoise and in other maternity units throughout the country.

The review and HIQA report have also “resulted in many improvements in Portlaoise Hospital’s maternity unit”, said the HSE.

These include:

  • New management and governance arrangements
  • The development of quality safety and risk management structures
  • A formalised arrangement with the Coombe maternity hospital
  • The appointment of a Clinical Director to improve clinical integration on maternity services
  • The appointment of additional midwifery and specialist nursing staff for maternity services.

This report has also been a “key driver” for the development of improved services in all maternity units throughout Ireland, it said.

This includes the implementation in all hospitals of the National Early Warning Score (NEWS) and the Maternity Early Warning System (IMEWS) in the 19 maternity units.

There has also been the launch of standards on bereavement services for families affected by adverse outcomes, and the development of mandatory Cardiotocography (CTG) trace training.

A National Implementation Group has also been established by the HSE to drive the agreed action plan arising from the Chief Medical Officer and HIQA reviews of Portlaoise.

The plan is informed by the experience of the Molloy family.

The HSE concluded:

Many families have been affected by adverse outcomes in our maternity services over the past number of years. The HSE deeply regrets the distress and anguish caused to these families for its failure to respond in a timely and empathic way to these issues. It is the Molloy family’s expressed wish that the publication of Baby Mark’s report will ensure that recommendations will be implemented nationally, inform the National Maternity Strategy and, most importantly, prevent unnecessary suffering, injuries and loss of life.

Read: Baby’s remains squeezed into tiny box and given to parents>

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