Portiuncula Hospital is not "any worse" than other hospitals of the same size the author of the Clinical Review of Maternity Services at the hospital between 2008 and 2014, Professor James Walker, has said.
He told RTÉ's Morning Ireland that it was a combination of inadequacies in resources and staffing levels that led to a number of failures, which led to the serious harm and death of babies.
Prof Walker said a lack of staff at midwifery level and consultant level was key to many of the problems.
“As soon as things go well you can cope, but when things go wrong there were not enough people around to assist.”
Big reviews were not the way to solve these problems, he said. They should be solved at a local level.
Due diligence
He added that if there had been due diligence or open disclosure at the time of the incidents involved then the report would not have been necessary.
“The report really is a reflection of the problem of not talking to people, not investigating and not accepting that errors have been made and they can improve.”
Prof Walker criticised the lack of an open disclosure approach to care in some cases — including a situation where a C-Section was carried out after the baby had died.
He also said that training and background training for younger doctors was inadequate. Individuals did not upskill or train to keep skills up and the infrastructure was not there to investigate things that went wrong and to learn from them.
The lack of a liaison or bereavement midwife to talk to families whose babies had been transferred to other hospitals also led to a breakdown in communication, he said.
Patient groups very often are the people that insist on getting something reviewed, pointed out Prof Walker.
Neonatal care
The report, which was commissioned in January 2015, examined the delivery and neonatal care of 18 babies at the Ballinasloe, Co. Galway, hospital and found serious failings in maternity care led to the death of three babies and the serious injury of three more.
Of the 18 births examined by the review team, six involved either still-births or the death of the baby shortly after delivery. There were failures in care in four of these cases and “key casual factors” in three, which if handled differently would have likely led to a different outcome.
Of the babies who survived, six suffered injury including life-long disability. One suffered Hypoxic Ischaemic Encephalopathy (HIE) which can result in brain damage. Another had a skull fracture, asphyxia and has been diagnosed with epilepsy.
In three of these cases better hospital care would have led to improved outcomes, the report said.
The main failings identified by the review were a lack of available senior staff, especially on evenings and weekends, a lack of training in midwifery and poor communication with staff.