Mr. Ollie Kelly:

We were also told at the meeting that they had never seen anything like this before and never wanted to see anything like it again. We were told that the nurse and doctor were very sympathetic and very sorry and that if we wanted to, we could meet them to hear their apologies.

A question was asked about reviews. We asked whether a systems analysis, related to severe accidents and deaths, had been carried out and were told that it had. We were also told that it had been completed and that we would have to apply to get it under the freedom of information regime.

On the way home in the car we pulled in to get a bite to eat. We discussed what we would do next. I forgot to mention that we said the doctor had failed to read the CTG scan properly and asked what could and would be done. We were told that they were not in a position to do this, that it was for another forum.

The language suggested that we would have to take a legal route to deal with the misreading. We were looking for disciplinary action and for the doctor to be shadowed and to learn from it. On our way home, we decided we would leave it at that. We accepted that the hospital had learnt from it. We had been told it had never happened before and that they never wanted it to happen again. At that stage, we believed that Mary Kate had died for a reason, that her death would make the maternity services in Portlaoise safer. We fully believed that. It is how we grieved as parents, by thinking that her death had been for the greater good.

Christmas came. We had never told our parents and families about what had happened and the fact that Portlaoise hospital had been to blame. We did not want to put that pressure on them. We wanted to get through Christmas and get back to some sort of a normal life and grieve for our little girl. Then, we saw the advertisements for "Prime Time", and we sat and watched Mark and Róisín Molloy, Shauna Keyes and Natasha Molyneaux talk about what has happened to them. We realised then that we were not the only ones, that Mary Kate, and many other babies, had died in vain and nobody had done anything about it. We were gut-wrenched. The following morning, I got up at 6 a.m. and watched it again on Sky+. We cried through it and we were disgusted at how we had been led to believe that we were the only ones and that it was "just one of those things". At Wednesday's meeting, it was a common theme that all the families had felt it had never happened before and that they were the only ones.

As time went on, we contacted the HSE and said we wanted to see Amy's report and find out the ins and outs of it. Only at that stage, when we requested it, was it posted down to me. In fairness to the man in the HSE who spoke to me, he told me it made for harrowing reading, that he was not happy with it and that he would have a proper system analysis review done. Given that it was a registered letter, I had to go and collect it. Although we had been told it was a system analysis report, it was a desktop report. According to the report, Amy had discharged herself against medical advice. When Amy got home from work, I had to sit down and tell her that according to her file notes she had discharged herself. It was a horrible thing for us, and it remains on her file in Portlaoise hospital. We had to go as far as an inquest to verbally right that wrong and have the doctor add to his deposition an apology for making us believe Amy had discharged herself against medical advice.

We went through the inquest procedure. As Amy said, she had to take the stand to prove her innocence, to prove that she had not walked out on her child. Members asked about the evidence that Mark and Róisín Molloy had gathered together. At that stage, they had given us that information and we knew, and everybody knew, that Mary Kate died due to a lack of interpretation of a CTG reading, and we wanted to bring it to a forum. This is the common theme among all the deaths, and everybody knew about it. The CTG interpretation failure happened because the hospital had failed to roll out or implement anything to improve the standard of care. Mary Kate died because the standard of care was poor in the hospital at that time.

It could have been, and should have been, improved. There have been recommendations. Deputy Doherty spoke about them and where they came from. Umpteen recommendations have been made going back years and none of them has been implemented because there is no one there to implement them or to follow up on them to make sure they are done. The HSE is great to say: "We accept these recommendations; we will put something in place." That is all fine for this week and next week but when the pressure comes off - we have a referendum coming up - it takes the foot off the gas. It fails to finish them out. It has finished out nothing. The CMR report has not been finished out.

Getting back to how we felt about all we were told at the December meeting, we asked if it ever happened again and if they had anything to tell us. We found out after meeting Mark and Róisín Molloy that the doctor was at their inquest the week before. That was the time to tell us that they had problems, it was the time for open and honest disclosure, the time to say, "We have errors here, we have made mistakes", and that is the time to implement the recommendations that have been made. I will not go on about it because it is still ongoing. It needs to stops now, it just needs to stop. Enough hurt and enough pain has been caused. There were more than 80 families in Portlaoise last weekend and those were the people who came forward. Members need to put the pressure on to get these recommendations implemented.