Portlaoise baby death report finds significant failings
Health chiefs have set out significant failings in the care of a baby and his mother six years after the newborn's death.
Baby Joshua Keyes died in the maternity unit of Portlaoise hospital on October 28 2009 with a review revealing concerns over how the foetal heart rate monitor was interpreted, the delay in delivery and an absence of foetal blood sampling.
Criticisms have also been made of the care and support provided to Joshua's parents Shauna Keyes and Joseph Cornally following their baby's death.
The standard of care for the mother and baby was investigated independently in 2014 to establish the facts of the case and give hospital management a list of improvements they could make to help prevent a repeat.
But the report is being published at the request of Ms Keyes and her partner.
The 24-year-old mother described the publication as closure.
"It's just about getting to the point now where I can close the door on all this and try to move on with my daughter," she told RTE radio.
Ms Keyes said the experience had matured her and that her son's short life would leave a profound legacy for other mothers and babies.
"I'm very very proud of Joshua. He didn't get to grow up or speak or show us what he's made of but he certainly left his impact on the world," she said.
Aside from the clinical care issues, Ms Keyes raised concerns following her baby's death about access to Joshua and that she was told she could only have a limited amount of time with him.
The family also thought the coffin used by the hospital was too small and that their baby appeared to be squeezed in.
Baby Joshua was also dressed in the clothing used in the special care baby unit where he was taken for intensive care after the birth but the family were not allowed to wash and change him.
The grief-stricken mother had also been told she would be given handprints, footprints and a lock of hair with a booklet but only got a footprint and they were not allowed to photograph him out of the coffin.
In a statement, the Health Service Executive (HSE) and the Midland Regional Hospital at Portlaoise reiterated an unreserved apology to the Keyes family over the care and the distress caused by the prolonged wait for the review.
Baby Joshua died about an hour after being born by Caesarean section. He suffered oxygen deprivation.
Twenty three recommendations were made, all of which the HSE said have been implemented in the maternity unit in Portlaoise including extra staff, foetal blood sampling, mandatory training for foetal heart monitoring equipment and new guidelines on the use of oxytocin, which is used to aid labour.
Other changes include bringing the Coombe Women and Infants University Hospital on board to manage Portlaoise maternity services, hiring a fourth consultant obstetrician in 2014 and seeking to appoint two other consultants to work in both hospitals and to appoint more neonatologists, again for both hospitals.
The HSE said the review of baby Joshua's death is also being used to improve maternity services in all hospitals including clinical guidelines on sepsis management, treatment of critically ill women during pregnancy and after birth, standards in response to bereavement and management of miscarriage.
Early warning systems are also to be used in all 19 maternity units.
Issues over maternity services in Portlaoise have been raised on several occasions in recent years and reviews of another 130 births where concerns were raised are under way.
The HSE added: "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 empathetic way to these issues.
"It is Shauna and Joseph's expressed wish that the publication of Baby Joshua's report will assist in ensuring that recommendations will be implemented nationally, and most importantly to prevent unnecessary suffering, injury and loss of life."