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

I thank Deputy Donnelly for sharing his time with me. It is approximately 12 months ago that I stood here to discuss the Portiuncula review. At the time, it was in the shadow of everything else that was going on, particularly CervicalCheck. Tonight I am again going to focus in the few minutes I have on Portiuncula. It provides a fantastic service but families have really been impacted and have lost loved ones. They have lost babies there, as the Minister acknowledged. Some 150 recommendations came out of the findings and the Portiuncula review. I was very cynical about the strategic release of the review last year. It happened within 24 hours of the CervicalCheck scandal breaking. Media coverage of it was minimal at the time. It is another shocking example of the failings of the HSE when it comes to parental care and the health of Irish women. As Deputy Donnelly said, the key findings concerned 18 cases that occurred between 2008 and 2014. Some 16 families have suffered greatly. Six babies have died. Of the 18 cases examined, serious errors occurred in ten which would probably have made a difference to the babies involved. The lengthy report included more than 150 recommendations, too many to mention. The main issues were problems in clinical care and problems with communication after delivery. The clinical care for most people attending the hospital was adequate, provided nothing went wrong. This was setting the bar far too low, hoping that everything would be all right because if it was not, God knows what would happen. Inadequacies were found in the staff's ability to interpret abnormal test results and respond appropriately, to escalate care levels where needed and to make timely clinical decisions, communicate effectively among themselves about the women and babies in their care. Surely these were basic skills that one would expect to be present in a maternity hospital at any time.

The lack of communication among medical and nursing staff on the ground was indicative of hierarchical structure, with figures who could not be questioned. The nurses on duty did not feel they could approach the consultants to have a two-way conversation. That is what was coming out of the report. On communication after delivery, it is frightening that this was similar to the problems with CervicalCheck, with information not given to women and parents in an appropriate or timely way. It is clear that this is not a once-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 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 tests or 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 there was a lack of openness, which seems to be a common theme across HSE, with no open disclosure and no informed consent. How much hurt could have been avoided with open communication?

I acknowledge that since the report was published 12 months ago, a director of midwifery, an assistant director of midwifery and a midwifery placement co-ordinator have been put in place. Many of the issues that arose in the review are being dealt with and it is important to acknowledge that. However, hurt is still being caused there. I wish to put on the record the story of baby Axel, who died in January 2017 and was not part of this review. Damien and Evonne met with Deputy Donnelly and me approximately ten months ago. Baby Axel died because of the type of ultrasound performed. Baby Axel was a very wanted baby who was conceived in a fifth round of IVF. The pregnancy was high risk for the mother. The contributing factors were the failure to recognise and appreciate risk factors, failure to listen to Evonne, poor communication and inadequate documentation. I ask the Minister to have somebody in his Department work with Damien and Evonne to bring closure to this case as there is much hurt attached to it.

For all women listening in, the most important thing we would like is to ensure that we have timely access to ultrasound. Women's access to ultrasound should not be determined by geography. It should be in place right across the country.

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