Review of 21 baby deaths called for by maternity care campaigners
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Campaigners for better maternity care are urging the Government to review 21 baby deaths over the last decade amid concerns that "similar issues" have occurred in each tragedy.
There has been at least 21 baby deaths in the past 10 years in Irish maternity units that were potentially avoidable.
These all happened since the Portlaoise baby deaths scandal emerged in 2014, which led to the publication of new clinical guidelines for maternity units across the country.
Of the 21 deaths now being highlighted, all but five resulted in a verdict of medical misadventure at inquest.
Suboptimal or a lack of cardiotocography monitoring of babies’ hearts and the mothers’ contractions played a key role in almost all the deaths, according to evidence heard at the inquests.
This was one of the main issues highlighted in the Portlaoise scandal, revealed in an RTÉ Investigates programme in 2014.
It centred around the deaths of four babies at the Portlaoise Hospital between 2006 and 2012, although a fifth death was later identified.
Numerous reports, including one by the then chief medical officer Dr Tony Holohan, were published along with reviews, new clinical guidelines and recommendations, and eventually, the implementation of a National Maternity Strategy.
Safer Births Ireland, which helped compile the list of deaths over the last 10 years, has called on Health Minister Stephen Donnelly to conduct a review of baby deaths since 2013.
Lisa Duffy, whose son Luke died on October 29, 2018, following what his inquest later ruled was a medical misadventure at Portlaoise Hospital, said: “There needs to be an urgent look at what is going on because, despite all the reports and recommendations, babies are still dying after alarmingly similar issues.
Krysia Lynch, chairperson of the Association for Improvements in Maternity Services Ireland, said: “What happened in Portlaoise was important enough for a National Maternity Strategy to be instigated.
"We needed guidelines and recommendations then to stop babies dying but here we are today, seeing the same thing all over again.”
The worst years for deaths where a series of mostly avoidable events took place before a baby died were 2014 and 2018, when four babies died in each year.
Most of the babies died in regional or general hospitals, with four dying after being born or treated at Portlaoise.
In one case that did not result in a verdict of medical misadventure, the coroner recently agreed to reopen the inquest early next year because new information has come to light.
A narrative verdict, which records the factual circumstances of a death, was initially given at the inquest into the death of Aaron Cullen on May 9, 2016, after he was born at Midlands Regional Hospital Portlaoise, but the case will now be re-examined.
Sinn Féin’s health spokesperson David Cullinane said: “Given the number of incidents, a lookback review conducted by the chief medical officer may be warranted to ensure that coroner recommendations are being implemented across all units to give confidence to expectant parents.
“It would be highly concerning if those recommendations have not been implemented.”
Minister for Health Stephen Donnelly was asked if he planned to look back over serious incident baby deaths since 2013, but has not commented.