Clare Daly (Dublin Fingal, Independent) | Oireachtas source

The release of this report came at the height of the CervicalCheck scandal and it landed with less impact than it deserved. The CervicalCheck scandal hit the headlines. It was, unfortunately, an opportunity for some politicians, who may have been asleep at the wheel regarding this issue for the past ten years, to get a few headlines for themselves by shouting and roaring. They woke up and realised that there are deep-seated problems in the HSE with respect to owning up to and learning from mistakes. It is unfortunate that the news cycle can only fit in one scandal at a time. Perhaps we can learn from that. It is important that we talk about the import of the Portiuncula report. I am sick of talking about the catastrophic failures in our maternity services. I refer to the failure to admit mistakes which gives rise to the failure to learn from them. That leads to catastrophic harm to women and their babies followed by delay, cover-up, denial and the whole brutal cycle starting all over again. More than anything else, that is what strikes me about this report.

The report was released three years late. It was so late that Warren and Lorraine Reilly, the parents of two of the babies that died in Portiuncula, Asha in 2008 and Amber in 2010, initiated legal proceedings because of the delay. We should say that Mr. Warren Reilly said he and his wife had never intended taking legal action. They thought that the review, which started in January 2015, would give them the answers they sought. It was, however, repeatedly delayed. They had no option but to take on a solicitor to try to get the answers that they desperately wanted and deserved. This is what happens in so many cases. People want answers; that is all they want. They are forced into court when they find the door slammed in their faces and then experience all of the trauma, stress and expense involved in getting those answers.

It is wholly unacceptable and we, as a society, have to address it. There is no doubt that serious failures are outlined in the Portiuncula report. Those failures led to or contributed to the deaths of six babies and injuries to six others. These major failures, which obviously had catastrophic outcomes for the babies, the women and for the families, should not come as a surprise to anyone. Although we constantly hear about the excellent quality of our maternity services, the sad fact is that there were 31 inquests into baby deaths in the Republic of Ireland in the ten years between 2007 and 2017. In June 2016, the investigation of baby deaths at Portiuncula hospital was only one of many. Of our 19 maternity units, seven at that time were either under independent investigation or involved in inquests. That is a shocking statistic. The story of Portiuncula is the same as it has been everywhere else for the families involved. In addition to their dreadful sense of loss, they have had to cope with the overwhelming stress of trying to get answers from frightened hospital staff and an intransigent HSE.

I will give one example. The inquest relating to baby Amber Reilly, who died in 2010, was held in 2011. The Dublin coroner, Dr. Brian Farrell, wrote to Portiuncula hospital asking for a full review of its maternity services to be carried out. In early 2015, Amber's father, Warren, said that the family had never been contacted about the review and had no idea if it ever happened. That is unbelievable. In February 2015, the Saolta University Health Care Group announced a review following the deaths of two other babies. It said that the review would cover a nine month period in 2014. The Reillys only learned of this review via the radio. They realised at once that it was not going to cover the deaths of their two babies, Asha and Amber, both of whom died in Portiuncula.

The Reillys were like so many families in this State. Mark and Roísín Molloy are struggling to get the truth about the death of their baby, Mark, in the Midland Regional Hospital in Portlaoise. The Reillys had to go public before the cases of their babies were taken into account. How utterly shocking is that? They only learned in 2015 - after the second review was announced - that a review of Amber's death had actually taken place in 2011 and that recommendations had been made. Even worse, those recommendations had not been followed through at that time. That is appalling. After the 2011 review was completed, a doctor at Portiuncula hospital wrote to the State Claims Agency about sending a copy of the review to the Reillys. He wrote that he did not see any place in the correspondence with the coroner where a copy of the report was required to be given to the parents of a deceased baby.

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