The Midland Regional Hospital, Portlaoise
The HSE has published an incident investigation report on failures in care provided to Mary Conroy while under the care of maternity services at Portlaoise hospital for the delivery of her daughter Róisín in November 2001.
Hundreds of South Kildare patients attend the maternity services at Portlaoise every year.
This report is being published at the request of, and with the prior consent of the Mary and Kevin Conroy from Portlaoise whose daughter has dyskinetic cerebral palsy as a result of a brain injury suffered at the hospital during birth.
The family battled the HSE in the courts from the time of her birth until reaching a settlement of €2.6 million in 2013. A further €9 million was awarded in 2015. They took an action against the health authority and consultant obstetrician Dr John Corristine.
While cognitively perfect, Róisín is unable to speak or make voluntary movements. Her parents have given up work to care for their daughter who is the eldest of three children.
The detailed 165 page investigation report higlights two key failings. It says there was a "failure to perform competently during a high risk labour regarding the assessment and monitoring of Baby Róisín and recognition of fetal distress".
It says this placed Mrs Conroy and Baby Róisín in a position of "unnecessary risk".
The report also says there was a failure to demonstrate "proper dedication, thoroughness, professional duty and responsibility as set out in professional regulatory guidelines.
It finds that this resulted in a "serious absence of the required level of professional communication expected during a
high risk labour and Baby Róisín being catastrophically injured at birth".
The report says the family highlighted a clear absence of communication between staff and the family during and after labour which the Investigation Team consider to be extremely concerning.
The family stated at a meeting with the Investigation Team on the 22nd November 2017 that;
"Had we only been told the truth on the morning of the 15th November, and not given untruths and misleading information, we could have accepted that people genuinely make mistakes or get it wrong sometimes.
"Incidents happen, sometimes with serious consequences. We were hold by Consultant Obstetrician and Gynaecologist A that
nothing could have been done, no signs that anything was wrong, that there is no way of detecting these things and we were just unlucky, the trace was ‘perfect’.
"Believing what we were told by Consultant Obstetrician and Gynaecologist A that we were “just unlucky” we tried to do our best for Róisín, meaning we were unable to access the appropriate care for our daughter.
"It was 9 years later when we found out what really happened and a further 3 years later (12 years in total) before we were able to get the right support for Róisín.
"We realised that there is really no avenue for individuals to be held to account, particularly if they retire, this investigation is our only recourse now, to find out why everything happened because we did not find out during the legal proceedings.
All the untruth’s and misleading information provided to us over a 12 year period ultimately resulted in Róisín being denied the therapies she needed to improve her quality of life and life expectancy," he said.
In its statement on publish the report HSE said acknowledged that there were significant failings in the care provided to Mrs Conroy and has apologised for these failings and for the consequent suffering and distress caused to Róisín and her parents.
Mr Trevor O Callaghan, Chief Executive of the Dublin Midland Hospital Group reiterated this apology to the Conroy family and acknowledged that neither this apology nor the publication of this report can negate the suffering and distress experienced by Róisín and her family.
“I would like to sincerely thank Mr and Mrs Conroy for working with the investigation team to complete this review and acknowledge the lengthy and difficult process it has been for them. The Hospitals failure for several years to acknowledge or address the deficiencies in care identified in this report was unacceptable and not what is expected from our services. Lessons have been learned, changes have been implemented and we are committed to providing the highest standards of care to all patients. This report and its recommendations will be shared with all maternity services through the Women & Infants Programme and other relevant agencies to inform best practice,” he said.
The HSE said that to date some of the key changes in Portlaoise Hospital maternity services include: new management and governance arrangements; significant investment in staff recruitment and training including the appointment of additional midwifery and specialist nursing staff, and the signing of a Memorandum of Understanding between the HSE, on behalf of Portlaoise Hospital, and the Coombe Women and Infants University Hospital, including the appointment of a Clinical Director to improve clinical integration and collaboration across maternity services within the Hospital Group.
The HSE said these changes would continue to enhance clinical services and quality and safety structures at the Hospital and contribute to the on-going integration between the two sites.
The investigation was commissioned in 2016 and carried out by: Ms Deirdre O’Keeffe, Quality Improvement Division, Health Service Executive (Investigation Chairperson); Ms Susan Temple, Quality and Safety Manager, Dublin Midland Hospital Group,
Health Service Executive; Dr Francois Gardeil, Consultant Obstetrician and Obstetrician, Wexford General
Hospital, Ireland East Hospital Group, Health Service Executive.