Anne Rabbitte (Galway East, Fianna Fail) | Oireachtas source

I thank my colleagues for sharing their time with me. I had my baby in 2005 and was fortunate. I gave birth in Portiuncula hospital and had a very good experience. It is important to put that on the record at the outset. I attended the briefing session in Ballinasloe on the night it was announced. Maybe I am cynical, but the strategic release with only 24 hours' notice to coincide with the CervicalCheck scandal meant minimal media coverage and that it flew under the radar. It was a cynical move by HSE at a time when people were at saturation point when it comes to national scandals and the failings of our health system. It is another shocking example of the failings of HSE when it comes to perinatal care and health of Irish women.

The key findings from the investigation of 18 cases that occurred from 2008 to 2014 were as follows. Sixteen families have suffered greatly, including one family that lost two babies. Six babies have died. Of the 18 cases examined, serious errors occurred in ten cases which would probably have made a difference for the babies involved.

The lengthy report included more than 150 recommendations - too many to mention here. Not least was the lack of clinical governance and proper incident management. The main issues were problems in clinical care and problems with communication after delivery. For most people attending hospital, clinical care was adequate provided nothing went wrong. This is setting the bar far too low, hoping that everything will be all right because if it is not, who knows what could happen.

Inadequacies were found in staff ability to interpret abnormal test results and to respond appropriately, escalate care level when needed, make timely clinical decisions, and communicate effectively among themselves about women and babies in their care. Surely these are basic skills. The lack of communication among medical and nursing staff on the ground is indicative of a hierarchical structure in which those higher up cannot be questioned. It is frightening that problems with staff communication after delivery are similar to problems with CervicalCheck. Information was not given to women and their partners in an appropriate or timely way. It is clear that this is not a one-off for the HSE but rather something that happens routinely.

In only 20% of cases was communication to parents about what had happened to their baby deemed satisfactory. Most women felt that they were not listened to before or during labour, that their concerns were dismissed by staff, and that no one explained how unwell their babies were and why. There was no chance to debrief about what had happened. Women did not understand why particular tests and procedures were being carried out. If people do not understand what tests are about, how can they give informed consent? Technically, to proceed without consent is a criminal offence. It was generally felt that there was a lack of openness. This seems to be a common theme across HSE with no open disclosure and no informed consent. How much hurt could have been avoided by open communication? What else are we not being told?

Many of the key recommendations are basics and would be standard practice, including clinical handover, staffing ratios, proper induction of new staff, appropriate leadership, the presence of senior staff on wards, and following best practice guidelines. I know I am out of time, but on the night of the presentation, I was there flicking through the report, as anyone else would do. What stood out for me was the lack of appropriate midwifery-led care either in the clinics or on the labour ward. In two cases when appointing the senior midwifery staff member, she was not qualified as a midwife. That is unbelievable in a maternity hospital.

Pat Nash described the situation in Ballinasloe that evening.

Nurses were not talking to each other, the level of communication was bad and personal issues were getting in the way and affecting how decisions were being made.

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