Report highlights poor treatment
The grieving parents of four babies who died in similar circumstances in the same hospital suffered appalling treatment by medics and health chiefs.
The country's chief medical officer declared Portlaoise maternity unit unsafe and ordered out the old management in a damning review which identified unprofessional and insensitive staff and mothers and fathers put through unacceptable anguish.
Dr Tony Holohan highlighted one especially-distressing finding where dead babies were transported in the boot of a taxi to Tullamore hospital for post mortem.
His review also found a baby suffered hypothermia on transfer to another hospital because an incubator was not working in an ambulance.
The investigation - to be followed by an inquiry by the Health Information and Quality Authority (Hiqa) - was sparked by repeated demands for answers by the parents of four babies who died in the unit.
It found the mothers and fathers were unfairly denied information on the deaths and treated with limited respect, kindness, courtesy and consideration after raising concerns.
Health Minister Dr James Reilly said he wants new rules ordering a coroner-led inquest if any baby dies once labour has commenced.
"I'm at a loss as to explain why parents would be treated like this," he said.
Dr Reilly disclosed that only one medic at Portlaoise has been subject to investigation by their relevant professional, medical body over the mistreatment.
All four babies - Katelyn Keenan, Joshua Keyes-Cornally, Mark Molloy and Nathan Molyneaux - died either during labour or within seven days of birth at different times from 2006.
A feature common to all of their deaths was anoxia, oxygen starvation to the brain. It is believed foetal distress was not properly recognised or acted on while mothers were in labour.
Calls for an independent inquiry were led by parents Mark and Roisin Molloy whose son Mark died 22 minutes after birth at the hospital on January 24 2012.
Mr Molloy said publication of the report was a vindication of their grievances but a day of mixed emotions.
"For us, when everything is implemented, when we have statistics we can rely on, safe maternity units, no-one is going to say to us, 'here, well done, have your little boy back'," he said.
The Molloys, from Co Offaly, who had to seek to have their son's death register changed from stillborn to newborn, sought explanations from the HSE for two years.
Dr Holohan's damning review found a culture of insensitivity among staff in the Portlaoise maternity and paediatric units.
:: Backs were being turned, honest accounts were not given, unprofessional behaviour and language was frequent and a lack of empathy common.
:: Younger patients were spoken to through their mothers rather than directly, leaving them feeling judged.
:: More than one member of the senior clinical staff at the hospital invited families to sue.
:: Further distress was caused in the immediate aftermath of perinatal deaths - grieving mothers were not necessarily moved away from nursing mothers; practices for handling, dressing, bathing and photographing dead babies were at best variable; and appropriately sized coffins were not always available.
"These accounts were powerful, clear and consistent," Dr Holohan's report found.
The chief medical officer said the families who were refused information blamed themselves for something they had no responsibility for.
Two of the af fected families met Dr Reilly and Dr Holohan in the wake of an RTE Prime Time programme earlier this year which exposed the families' quest for answers and treatment by hospital chiefs and prompted the inquiry.
Dr Holohan's report, which includes a raft of recommendations on better maternity care, confirmed that information was withheld from families for no justifiable reason.
In a statement the Health Service Executive (HSE) reiterated its apology for poor care when parents most needed compassion, candour and courtesy.
"The HSE and the hospital accept that there were significant shortcomings in the cases referred to in the report, particularly in relation to the level and quality of care afforded to the patients in question and to the sub-standard communications with their families," it said.
"The HSE and the hospital have earlier apologised unequivocally to the families for these failings."
The review also identified failures at a national level.
Some 1,983 births were recorded at Portlaoise in 2013 and 17,025 since 2006, but major discrepancies have been identified across the health system on how perinatal deaths and still births are recorded.
It said the current system was disparate and leads to confusion and duplication adding to the workload for maternity units and strain on scarce health service resources.
Dr Holohan's report said that data from Portlaoise could have flagged suspicions of problems at the maternity unit.
Records showed birth rates rose very quickly over a short period.
They showed a number of "never events" - medical errors which should not have occurred - while there were also a number of other serious adverse events and a rise in notifications of adverse incidents.
The figures showed a significant increase in transfers out of Portlaoise for both maternity and paediatric care and a higher than expected rate of obstetric claims.
Dr Holohan's report found: "While there was awareness that the service was under pressure, there does not appear to be any evidence that monitoring of how this might have been impacting on patient care was taking place."
A transition team has been put in control of maternity services at Portlaoise.
The director general of the HSE, Tony O'Brien, has written to staff in the agency highlighting the importance of honest communications with patients and families.
He warned that failure to do so "erodes public confidence in health services, lets down the public and lets down the service as a whole".