Mr. Mark Molloy:

Yes. Despite being informed by the hospital obstetric and midwifery management that the death of a healthy baby during labour was extremely rare, it became apparent to us very early on that we were not the only family whose healthy child had died in similar circumstances at the hands of this and other regional maternity units nationally.

Yes. Despite being informed by the hospital obstetric and midwifery management that the death of a healthy baby during labour was extremely rare, it became apparent to us very early on that we were not the only family whose healthy child had died in similar circumstances at the hands of this and other regional maternity units nationally.

Consequently, a huge burden of responsibility became the overriding drive to get action and intervention to save other families suffering the heartache and loss that we were enduring. The details of our children's deaths, injuries to others and the experiences of families in their dealings with the hospital and HSE have been relayed to HIQA and formed much of the basis of their report issued on 8 May 2015. Therefore, we aim to use this opportunity today to set out the extent and steps in which we engaged since January 2012 to bring our concerns regarding the safety of these maternity units to people who had a duty to act and intervene.

In the immediate aftermath of Mark's death, we made a complaint to hospital management at the Midland Regional Hospital, Portlaoise. At every juncture thereafter, as we encountered a lack of action and-or urgency, we continually moved up to more senior HSE management levels, first regionally and then nationally, conveying both our own story and those of others of which we had learned since Mark's death, as well as our fears for the safety of other patients attending the unit. We also sent correspondence and sought meetings with the Secretary General in the Department of Health. At every single stage, we firmly believed we were informing each new level of management encountered of serious patient safety issues of which they were totally unaware.

We later learned of the State Claims Agency's attempt at intervention in 2007, the O'Doherty and Fitzgerald report following the breast cancer scandal at the Midland Regional Hospital, Portlaoise in 2008, staff concerns raised on numerous occasions, the Avalon foetal monitor operational recall in 2009 and update in 2011, the completion of and recommendations from Nathan Molyneaux's investigation in August 2011, and the completion of and recommendations from Katelyn McCarthy and Joshua Keyes' investigations in November 2011. Despite this, our concerns continued to be ignored.

The reaction and intervention noted in the aftermath of the publicity surrounding the death of Savita Halappanavar were apparent. We eventually made the difficult decision after two years of rigidly sticking with the HSE's procedures that highlighting our concerns through media was the only option if any meaningful intervention and-or change were to occur. The following schedule sets out a record of the main correspondence we have on file in the period of February 2012 to April 2013 in relation to Mark's death and our serious concerns for the safety of mothers and babies attending the Midland Regional Hospital, Portlaoise. I will take the committee through the schedule. It is quite long but it paints a picture when one reads it from start to finish.

SCHEDULE OF CORRESPONDENCES IN RELATION TO MARK'S INVESTIGATION and WIDER PATIENT SAFETY CONCERNS

Date	Sent/Received	To/From	-
22 February 2012	Sent to	Manager - Midlands Regional Hospital Portlaolse and copied to National Director for Quality and Patient Safety	Letter of Complaint
28 February 2012	Minutes of Meeting	Governance - Midlands Regional Hospital Portlaoise	Baby Mark's Investigation
30 March 2012	Minutes of Meeting	HSE Risk Manager - Dublin Mid Leinster Region	Baby Mark's Investigation
1 July 2012	Sent to	Secretary General in Dept of Health	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
18 July 2012	Sent to	HSE Assistant National Director of Acute Services	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
15 August	Sent to	NPEC - National Perinatal Epidemiology Centre	Incorrect Stillbirth Classification and Concerns Regarding Maternity Services at MRHP
21 October 2012	Sent to	Secretary General, Department of Health	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
22 October 2012	Sent to	HSE Assistant National Director of Acute Services	Informing of Decision to Escalate to National Level
22 October 2012	Sent to	HSE National Director for Quality and Patient Safety	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP and Meeting Request
25 October 2012	HSE Internal email	HSE Risk Manager Dublin Mid Leinster Region to Co-Chairpersons NIMT	Update on Baby Mark's Investigation
26 October 2012	HSE Internal email	HSE National Director for Quality and Patient Safety to HSE Co-Chairpersons NIMT	Proposed Response to Family Regrading Concerns Raised
26 October 2012	HSE Internal email	HSE Co-Chairpersons NIMT to HSE National Director for Quality and Patient Safety	Discussions Regarding High Rates of Harm in Maternity and Other Services Nationally
26 October 2012	Received From	Secretary General, Department of Health	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
26 October 2012	Received From	HSE Director General	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
30 October 2012	Received From	HSE National Director for Quality and Patient Safety	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
21 November	Minutes of Meeting	Co-Chairpersons- NIMT	Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP
23 November	Sent to	National Director for Quality and Patient Safety HSE	Request for Meeting
25 November 2012	Sent to	HSE Director General	Baby Mark's Investigation Delays andConcerns Regarding Maternity Services at MRHP
30 November 2012	HSE Internal email	HSE Risk Manager - Dublin Mid Leinster Region to HSE National Director for Quality and Patient Safety cc HSE Co-Chairpersons NIMT and HSE Assistant National Director of Acute Services	Update on Baby Mark's Investigation Delays and Concerns Regarding Maternity Services at MRHP

On 22 February 2012, we sent a letter to the manager of the Midland Regional Hospital, Portlaoise and copied the national director for quality and patient safety. It was a letter of complaint concerning Mark's birth and death. The minutes of a meeting we had with the governance of the Midland Regional Hospital Portlaoise are dated 28 February 2012. The subject of the meeting was Mark's investigation. The minutes of a meeting dated 20 March 2012 are for a meeting with the HSE risk manager for the Dublin Mid-Leinster region the subject of which, again, was Mark's investigation. Correspondence dated 1 July 2012 was to the Secretary General of the Department of Health, facilitated through Patient Focus and relating to delays in Mark's investigation and concerns on the maternity service at the Midland Regional Hospital, Portlaoise. On 18 July 2012, a letter was sent to HSE national assistant director for acute services on delays in Mark's investigation and concerns about services at Portlaoise. On 15 August 2012, a letter was sent to the National Perinatal Epidemiology Centre, or NPEC, on the incorrect classification of Mark as stillborn and concerns about the maternity services at Portlaoise.

On 21 October 2012, a letter was sent to the Secretary General of the Department of Health on delays in Mark's investigation and concerns about services in the maternity unit at Portlaoise. On 22 October 2012, a letter was sent to HSE assistant national director for acute services informing him of our decision to escalate to national level due to inaction. On 22 October 2012, a letter was sent to the national director for quality and patient safety on delays in Mark's investigation and concerns about services in the maternity unit at Portlaoise and requesting a meeting. Next is a HSE internal e-mail dated 25 October 2012 from the risk manager of the Dublin mid-Leinster region to the co-chairpersons of the national incident management team, or NIMT, regarding an update on Mark's investigation. Next is another HSE internal e-mail from the national director for quality and patient safety to the HSE co-persons of NIMT on proposed response to the family regarding the concerns raised. Next is another HSE internal e-mail from the co-chairs of NIMT to the national director for quality in patient safety discussing high rates of harm in maternity and other services nationally dated 26 October 2012. Also on 26 October 2012 is correspondence received from the Secretary General of the Department of Health on delays in Baby Mark's investigation and concerns about services in the maternity unit at Portlaoise. Also dated 26 October 2012 is correspondence received from the HSE director general on delays in Mark's investigation and concerns about services in the maternity unit at Portlaoise. On 30 October 2012 there is correspondence received from the national director for quality and patient safety on delays in baby Mark's investigation and concerns about services in the maternity unit at Portlaoise.

On 21 November 2012 are dated minutes of a meeting Róisín and I had with Sheila present with the co-chairs of the national incident management team on Mark's investigation and concerns about services in the maternity unit at Portlaoise. That was a three-hour meeting. On 23 November 2012 is dated correspondence sent to the national director for quality and patient safety requesting a meeting as we were very unhappy with the meeting of 21 November. Correspondence dated 25 November 2012 was sent to the HSE Secretary General on delays in Mark's investigation and concerns about services in the maternity unit at Portlaoise. On 30 November 2012 there was an internal HSE e-mail from the HSE risk manager for the Dublin mid-Leinster region to the national director for quality and patient safety copying the co-chairs of NIMT and the assistant national director for acute services concerning an update on Mark's investigation delays and discussions regarding concerns at Portlaoise.

Dated 2 December 2012 are minutes of a meeting between the HSE director for quality and patient safety with Róisín and I in the presence of Patient Focus on Mark's investigation and concerns about Portlaoise. This was a three-hour meeting, again, which took place on a Sunday just before Christmas in Dr. Steevens' Hospital. Dated 3 December 2012 is a HSE internal e-mail from the co-chairs of NIMT to the HSE national director for quality and patient safety and HSE risk management for the Dublin mid-Leinster region on key actions agreed from a teleconference. Dated 6 December 2012 is notice of a meeting with no minutes received. It is on our file as just notice of a meeting between the HSE director general and the national director for quality and patient safety and it may be that an agenda item was baby Mark Molloy's investigation. Dated 8 December 2012 is a HSE internal e-mail from the national director for quality and patient safety to the HSE co-chairs of NIMT on concerns regarding the maternity services at Portlaoise.

Correspondence dated 10 December 2012 was a mapping document to the HSE, Health Service Executive, advocacy team on non-clinical complaints against HSE response and actions in dealing with Mark's death. Essentially, while there was the clinical investigation going on in to Mark’s death, we were also very unhappy with the way we had been treated to that point. We said people had misled us from day one which needed to be looked into. Accordingly, a separate investigation was launched by the HSE into that.

Correspondence on 13 December 2012 concerned a HSE internal e-mail from the HSE co-chairpersons NIMT, national incident management team, to the HSE national director for quality and patient safely on discussions regarding high rates of harm in maternity and other services nationally.

Correspondence was sent on 11 January 2013 to the HSE national director for quality and patient safety, amending omission from minutes of meeting of 2 December to include review of all perinatal deaths at Portlaoise.

On 13 January 2013, correspondence was received from the HSE national director for quality and patient safety confirming data from Portlaoise would be included as an action item for national director for quality and patient safety.

Correspondence on 15 January 2013 involved a HSE internal e-mail from the national director for quality and patient safety to the HSE co-chairpersons NIMT confirming data from MRHP, Midland Regional Hospital Portlaoise, should be reviewed.

On 13 February 2013, correspondence was sent to the HSE national director for quality and patient safety on baby Mark's investigation delays and the need to act on concerns regarding this unit.

Correspondence on 15 February 2013 comprised a HSE internal document from the HSE national advocacy unit to the HSE national director for quality and patient safety on clinical complaints to be investigated by NIMT to national director for quality and patient safety HSE. The advocacy team sent certain elements on to the director stating it was outside the scope of its investigation and should be handled by the director for quality and patient safety.

Correspondence on 13 March 2013 involved a HSE internal document from the HSE national director for quality and patient safety to the HSE national director for service user advocacy which was a response to above correspondence of 15 February 2013 stating he would take on that role.

Correspondence on 12 April 2013 comprised a HSE internal e-mail from the HSE national director for quality and patient safety to the HSE co-chairpersons NIMT, Department of Health and the HSE head of legal services for a request by the former Minister of State, John Moloney, on our behalf for a meeting with the Secretary General of the Department of Health regarding Mark's investigations and concerns for wider patient safety. The meeting did not happen.

The last correspondence was received in April 2014 regarding a HSE internal document prepared by the director of nursing at Portlaoise hospital on 30 January 2012. It was a desk-top review confirming the reasons Mark died, six days after he had died.

In October 2013, Mark's investigation report was finally completed. Following this, we requested a meeting and met with the HSE national director for quality and patient safety and the HSE national director for patient advocacy to discuss the HSE's plan for the implementation of the 43 recommendations contained in Mark's report which had both local and national service implications. Despite all of the foregoing meetings and correspondences set out, the numerous other correspondences, phone calls and meetings, coupled with the completion and findings of the investigation, both said they were there to listen to our story. At that stage we made the decision to speak to RTE's investigations unit.

Following the “Prime Time" investigation unit's programme which aired on 31 January 2014, Patient Focus received in excess of 180 calls from concerned parents. We were contacted directly by Amy and Oliver whose daughter, Mary Kate, had passed away in May 2013 in similar circumstances. We were also contacted by Nicki and David Reddington whose daughter, Síofra, passed away in February 2013 and another couple whose son received a severe birth injury in November 2013. All of these birth outcomes were after the above highlighted correspondences and meetings.

The harrowing stories of the many people who spoke of so many deaths and life-changing injuries at the meeting with the Minister for Health, Deputy Varadkar, last Wednesday, 13 May, after years of uncanny accounts of being misled, ignored and silenced by the HSE, disclosed the extent of the depths of this scandal.

We conclude by stating we vehemently disagree that this scandal was the result of ignorance or a "lack of escalation". There appears to have been an attempt at both local and national level to suppress repeated known red flags, which perpetuated failings, leading to repeated deaths and injuries, at huge emotional, physical and financial cost to families and patients.

Ms Delahunt will put the following recommendations to the committee.