Staff at Portlaoise hospital sent the wrong placenta for testing following the stillbirth of a baby in the maternity unit, a Health Service Executive report has found.
The baby’s body was sent to the Rotunda Hospital in Dublin for a postmortem following his death in 2007 but the placenta from another mother was sent to the pathology lab in Tullamore hospital, according to the report. The results from this test were forwarded to the Rotunda, which already had the baby’s placenta. Subsequent analysis showed the placenta in the Rotunda was a match while the other placenta probably came from another mother who gave birth in Portlaoise on the same day.
The report is highly critical of the care provided by the hospital to mother and baby and identifies five “care management problems” that arose before and after the delivery.
The 27-year-old mother, who is not identified in the report, was given an excessive dose of a drug administered to speed up labour. There was also a delay in carrying out an emergency Caesarean section.
The report is critical of a lack of bereavement and other supports in place in Portlaoise at the time for parents who have experienced the loss of a baby.
Similar criticisms were made in official reports into other baby deaths at the hospital that featured in a Prime Time programme in 2012, but this case precedes the others by a number of years. Changes in staffing, procedures and supports for parents have been introduced following this controversy.
Waiting list
The mother was seven weeks pregnant when she was referred to the hospital by her GP but was not seen until 19 weeks because of a waiting list. Her baby was found to be small and was diagnosed with inter-uterine growth restriction.
The mother was admitted at full term on March 5th, 2007, and started on prostaglandin, a drug to induce labour, at 10am. The labour did not progress and, at 5.05am the following day, an emergency section was ordered. The baby was stillborn at 5.35am.
After being alerted to the situation, the baby’s father arrived in the maternity ward and had to wait alone in what he described as “a storeroom” for 10 minutes. A junior doctor then told him his baby had died and his wife was still in theatre. He was then left alone for another 10 minutes before he could join his wife.
In the report, the mother is critical of the “emotional distance” maintained by staff and of the sense of grief from being among women caring for their newborn babies.
“She describes a midwife coming into her room saying that she needed to get a lock of her baby’s hair and take his hand and foot prints for the memento book and proceeded to do so without further discussion or explanation.”
Expert assessment
In an expert assessment, Dr Peter McParland, consultant obstetrician at the
National Maternity Hospital
, says the mother received substandard care in that she was administered too much prostaglandin in too short a time.
The Caesarean section was carried out 46 minutes after the original decision was made, longer than the 30 minutes recommended in UK guidelines. The report says it is difficult to conclude the outcome would be any different if the baby had been born 16 minutes earlier.
Dr McParland says it is possible the baby would be alive if his mother had been induced a week earlier but he cannot state this for certain.
