Broader timeframe needed for review into baby and maternal deaths, say campaigners

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Advocacy group Safer Births Ireland has welcomed the HSE’s announcement that it is to conduct a review into deaths during childbirth – but has said that the scope of the inquiry must be broadened.

On Thursday, the HSE announced that a confidential review into baby and maternal deaths during childbirth will start later this year, covering the years 2021 to 2023.

Safer Births Ireland, a campaign group for women and families impacted by baby deaths and birth injuries, has called on the government to set up an independent review into perinatal deaths. The group have raised concerns around non-adherence to standards and guidelines in Irish hospitals, women not being listened to, foetal heartbeat monitoring, and apparent failings to recognise signs of labour and delayed deliveries.

The group previously urged the government to launch a review into the 52 baby deaths which took place over the last decade, amid warnings that similar issues had occurred in each tragedy. According to Safer Births Ireland, there have been at least 21 baby deaths in the past 10 years in Irish maternity units that were potentially avoidable.

All of those deaths occurred following the emergence of the Portlaoise baby deaths scandal in 2014, which prompted the publication of new clinical guidelines for maternity units across the country.

Of the deaths highlighted by the group, all but five resulted in a verdict of medical misadventure at inquest.

Co-founder Lisa Duffy told Gript that there had been a substantial number of baby deaths in Ireland in the last decade, many of which have been documented by inquests, clinical reviews, and court cases. 

Ms Duffy helped establish Safer Births Ireland after losing her baby boy, Luke, who died in labour at Portlaoise hospital in 2018; A verdict of Medical Misadventure was recorded at the 2022 Inquest into the death of baby Luke Duffy, who was tragically delivered stillborn on the 30th October 2018 at the Midlands Regional Hospital in Portlaoise.

Initially, Ms Duffy was told that her baby’s death was unexplained by a doctor/midwife, and was just “one of those unfortunate events,” which led her to look for answers through multiple inquiries. The Hospital later apologised for the infant’s death.

Speaking to Gript, Ms Duffy said that while the group welcomes the announcement of a HSE investigation, many maternity advocate organisations have their reservations and continue to campaign for a National Independent Inquiry into Baby Deaths, Maternal Deaths and Birth Injuries. She also described as “bizarre” the “lack of media attention” regarding maternal deaths, after three women died last month.

“We believe a timeframe of three years (2021, 2022 and 2023) is not significant enough to provide the necessary threads and issues continuously presenting throughout patient shared experience and within these cases. A ten-year inquiry would be more constructive, transparent and lead to a definitive approach towards the implementation of change in quality and patient safety and its review process, within our maternity system.”

The group have raised questions over why the Inquiry is to only span three years, and why it is set to be confidential.

“It’s definitely positive news, and our message has reached a broader audience over the last number of months, which will hopefully mean the government steps up now,” Ms Duffy told Gript.

“When we went to the Dail in November, we had called for a ten-year timeframe. 

“We don’t know why this timeframe has been given. The terms of reference for the review has not been set yet, but we would say it’s too short of a timeframe. When we went to the Dail in November, we had called for a ten-year timeframe, which would allow for more scrutiny with regard to where things are going wrong, and would also allow for better understanding of where extra training is needed, or where extra staff are needed. For example, we know bank holiday weekends are problematic.

“In my own case, for example, how do you actually diagnose when a woman is in labour, with back labour being particularly important? Things like heart monitoring also need to be highlighted. With regard to the two cases we reviewed, these are common themes which we are seeing over and over again when it comes to preventative deaths,” Ms Duffy continued.

 “As an organisation, we want these preventative deaths to be exposed, and a strategic plan to be put in place detailing how changes would be adopted nationally in all maternity units, and to have these guidelines in place because it is clear that the guidelines there at the moment are not sufficient.

“This review must be centred around parents, and there must be consent given by parents to have their medical files reviewed. There must be full, open disclosure in all of this going forward, and publishing the findings would be key. It has been reported that this review will be confidential, which does pose a potential worry,” she added.

MATERNAL DEATHS

Ms Duffy also pointed to the three recent maternal deaths which took place in the State last month, adding that “the lack of media attention” regarding these deaths was “bizarre.”

External reviews are to be conducted into the deaths of two pregnant women at maternity units in Kerry and Cork in June while a third maternal death occurred in Drogheda last month.

Data on maternal deaths indicates there were 24 deaths between 2019 and 2021, but this includes women who died during pregnancy, or within one year of pregnancy.

“When it comes to maternal deaths, they know they have happened in Ireland – but not to the extent we have seen recently. The lack of media attention regarding this is baffling. Back in April, we called for an inquiry into maternal deaths, baby deaths, and birth injuries – so we want this review to have a broad focus, and we believe that the scope of the review has to be broader. This review will not take into account the recent maternal deaths in our hospitals, or deaths which took place before 2021. 

“For us, it comes down to women not being listened to on our maternity wards. As a consequence of that, we are seeing huge detriments to babies and mums. How many birth trauma stories have we seen circulated in recent months? This is an issue which has now become quite prevalent, and we welcome the fact that people are opening up on this issue. However, this doesn’t take away from the tragedies which have happened, and the heartache families have been left with throughout this country.”

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Maria Maynes

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This article first appeared on Gript and is published here with permission

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