Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael) | Oireachtas source

This morning we heard harrowing reports from the parents of Mary Kate and Mark. They were upset, staff were upset and so were members. I thank Dr. Crowley for apologising. Has Mr. O'Brien apologised to the parents for what has happened? I may have missed it. Dr. O'Reilly has reported that things are improving and new systems have been set up. Can I have a watertight guarantee that what happened to baby Mark's parents, in terms of them e-mailing back and forth, trying to get information, will never happen to another parent who loses a child in a maternity unit? I was very concerned when I heard baby Mark's parents state that he was registered as stillborn. Is this normal practice in a hospital when a baby lives for a short time after birth to register that as a stillbirth?

I asked the parents numerous questions and thought they were very generous in their answers. I commented to the effect that we all know that human error can occur in a hospital. While they agreed and said that they understand that human errors happen, they argued strongly that failures must be investigated fully in order to be prevented in the future. I want to know, as do the parents, if a formal or informal decision was made by senior HSE staff or senior management in Portlaoise not to act on the human errors that occurred that day. As the parents said, nobody went into work that morning to cause harm. They also said that there are departments of audit, risk management, advocacy and complaints in the HSE. Are all of those departments still in existence and if so, could the witnesses tell us what they do?

I wish to ask the witnesses about the lack of a safety culture in the hospital in Portlaoise, as referred to in the executive summary of the HIQA report. Page 9 of that report reads as follows: "It is also evident that at this time, the hospital's senior management team did not collectively conduct formal safety walk-rounds". Is that happening now and is it happening in the other maternity units across the country? I find it incredible that this is not happening in our hospitals. Were the senior management and the people responsible suspended, reprimanded, put on paid leave? What happened to them?

The parents also mentioned the qualifications of staff that day and the fact that there was no-one available to carry out a CTG test. Had that been done, the baby could have lived. The witnesses have told us that staff are being trained in cardiac monitoring.

Is that the case in other hospitals? Can a mother who is to go into hospital this evening tonight or tomorrow to deliver a baby expect the staff to have been trained in cardiac monitoring?