The HSE has been told to urgently prioritise the need to learn lessons from patient fatalities, following an inquest into the death of a baby in the Midland Regional Hospital in Portlaoise last year.
It was one of eleven recommendations issued after a jury at Limerick Coroner’s Court returned a verdict of medical misadventure in the death of Mary Kate Kelly, who was stillborn on May 28, 2013.
Her mother Amy Delahunt, who was 34 weeks pregnant, had visited the maternity unit at the Midlands General Hospital in Portlaoise on May 21, 2013 when she was told everything was normal and sent home, even though a CTG showed significant decelerations on the foetal heart trace.
Tragically Ms Delahunt discovered at the Limerick Maternity Hospital the next day that her baby was dead.
She and her partner Ollie Kelly only discovered last January that there were four other baby deaths similar to hers at Portlaoise when she watched an RTÉ Prime Time programme.
Among the eleven recommendations made by the jury at the inquest into the death of Mary Kate Kelly was that all staff receive adequate and ongoing training on the interpretation of CTG traces.
The other baby deaths in Portlaoise had a number of themes in common with Mary Kate’s case, including the foetal heartbeat trace.
The jury at her inquest also recommended that patients not be discharged from hospital in a case of non-reassuring CTG or concerns regarding foetal movement without the consultant being consulted.
At Mary Kate inquest, mid wife Sally Hanford described how she urged the registrar Dr Chuck Ugezu who saw Ms Delahunt to have the CTG trace reviewed by the consultant on duty as she was concerned about the unprovoked decelerations in the foetal heart rate.
Ms Hanford - who had to leave the overcrowded assessment unit on a few occasions to look for more staff in the main hospital- told Dr Ugezu he could not stand over the trace and they needed to contact consultant obstetrician Dr Miriam Doyle who was duty in the maternity ward.
When the mid wife returned, to the MAU, Ms Delahunt had been discharged and told the keep a check of foetal movements overnight ahead of her scheduled anti-natal appointment in Limerick, the following morning where she was a patient.
In an addendum to his original deposition, Dr Chuck Ugezu, admitted he ought to have insisted she be kept in for further observation and steroid treatment when she presented to the hospital on May 21, 2013.
The jury at the inquest has also recommended that midwives and doctors should have clear written instructions and training on escalation of care to consultant level, and that patients discharged to monitor foetal movements should be given clear written instructions.
In the event of a sensitive situation arising such as the loss of a child, the jury recommends that that the parents be met for any follow up discussions at an external venue outside of the hospital to avoid further distress.
The HSE has also been urged to publish and be obliged to adhere to guidelines on adequate staffing levels in all maternity hospitals and to ensure its National Open Disclosure policy is implemented in full.
It should also ensure that systems are in place in order that a senior consultant and a senior nurse or midwife take responsibility for dealing with serious adverse events when they occur and appropriate training is provided in these cases.
A spokeswoman for the jury told the inquest the jurors believed “all of eleven recommendations are capable of being adhered to”.
Coroner John McNamara said there were very few words he could offer Mary Kate’s parents that would bring justice to what they have endured and suffered.
He said everybody at the inquest was moved by the heartrending and upsetting evidence and he knows Ms Delahunt and her partner will never get over the loss of Mary Kate.
“We all hope that circumstances like this do not arise and a similar situation will never arise again and lessons will be learned,” he added.