Colm Burke (Cork North Central, Fine Gael) | Oireachtas source

I join the Minister and colleagues in conveying my deep concern in regard to what occurred with the disposal of perinatal organs and the hurt and upset caused to the families. It is difficult enough to suffer a loss without having to also deal with what occurred in this case.

For most people, the birth of a baby is a happy event. It is also a time of celebration for an entire family. Currently, most pregnancies lead to the birth of a healthy baby. It can be easy to forget that this is not always the case. Alongside the excitement that accompanies most births, there is the ever-present and unwelcome shadow of pregnancy loss and perinatal death. Despite the many modern advances in obstetric and midwifery care, one in four pregnancies will end in a miscarriage and one in every 240 babies born in Ireland will die just before birth while a smaller number will die shortly after birth. Globally, more than 2.6 million babies are stillborn annually. The high emotion of expectation in pregnancy, which changes suddenly as a result of a miscarriage, stillbirth or neonatal death is a very difficult experience and it has a long-lasting impact on parents and immediate family members.

The national implementation group of the national standards for bereavement care following pregnancy loss and perinatal death published a report in July 2021. It is a comprehensive report, which deals with all of the issues and carries out a review of the progress which has been made over the past five years. What occurred in CUMH in March-April 2020 is regrettable and should not have happened. I understand that the South/South West Hospital Group and CUMH have apologised to the 18 families who have suffered as a result of this error, whereby organs retained by the hospital were sent for incineration. The perinatal pathologist became aware of the removal of the perinatal organs from the hospital mortuary in late April 2020 and immediately raised concerns with the relevant authorities. CUMH staff volunteered to take the lead role in openly disclosing the error and apologising to the parents. I understand from the chief executive of the South/South West Hospital Group that all 18 were families were contacted by it and that the supports of the CUMH bereavement and pregnancy loss team remain in place to provide ongoing contact care and support as required by the parents.

It is important to note that organs are retained for a only a temporary period. They are retained to allow the pathologist complete an investigation into the cause of death. There was a full review of all maternity units last year by the monitoring group. It recommended that all maternity units have access to mortuary facilities, with a suitable area for families to receive and spend time with a baby following a perinatal death. CUMH, which is one of the top four maternity units in the country, still does not have a dedicated area, despite it taking on perinatal autopsies from five other maternity units over the past 12 months. It is important that this issue be resolved at the earliest possible date.

Professor Keelin O'Donoghue, consultant obstetrician, who is monitoring the implementation of the national standards for bereavement care following pregnancy loss and perinatal death, has confirmed that staff in the maternity unit at CUMH were not aware that organs had been sent overseas for incineration until after it had occurred. She has also confirmed publicly that the implementation team she chairs was assured earlier this year by all 19 maternity units in the country, including CUMH, that they had guidelines in place on autopsy consent, the disposal of remains and the retention of organs and that they had access to suitable burial ground. I understand that CUMH has access to a burial ground, which it uses. This incident should not have occurred. The parents of 18 children and their immediate families have been adversely affected not only by the loss of their loved ones, but by what occurred in the disposal of the organs retained.

I understand there is an external review and the Minister gave them further clarification on this. However, no matter what review takes place, it must be speedy and take place in the quickest time, because all the families need full clarity in this matter. It is also important that all the other 18 maternity units around the country set out quite clearly that they are fully following the guidelines and that there has been no deviation from same.

The report published in July on the implementation of national standards for bereavement care makes 40 recommendations. The report sets out what progress has been made in the past five years in dealing with this issue in each of the 19 maternity hospitals. It is a 65-page report and it goes into this in detail. Each of the 40 recommendations must be implemented in full in each of the hospitals. We should also take on board a number of issues that came up in the report. Under the heading "Public Awareness", it suggests:

The ... [HSE] in collaboration with the professional bodies and advocacy groups should implement an ongoing educational campaign to raise awareness and recognition of pregnancy loss in Ireland. This would include the role of bereavement care in helping women and their families come to terms with pregnancy loss, both early and late.

It also recommends:

... [the HSE] in collaboration with the professional bodies should implement a public health education programme on late pregnancy loss and, in particular, how the risk of late pregnancy loss can be modified. This should be reflected in antenatal education websites and hospital information materials.

It also suggests:

Senior Management Teams in all 19 Maternity Units should ensure that there is a hospital nominated point of contact for parents who have experienced pregnancy loss or perinatal death and have questions regarding their care - to guarantee that they can easily access information and have questions answered regarding their care.

It also sets out that the HSE "...should work to establish a national screening programme for fetal anomaly in conjunction with the professional bodies and the Department of Health". It further states the HSE:

... should continue to engage with the Coroner Service of Ireland (involving the Departments of Health and Justice) regarding the clinical management of perinatal death cases in order to allow timely reporting to families and hospitals of provisional information on cause of death e.g., consideration to providing a draft autopsy report as per other jurisdictions, as well as facilitating communication between bereaved parents and Maternity Units.

There is no point in reports being published and us then putting them on a shelf to gather dust. All the recommendations in this report should be taken on board and implemented in all the 19 maternity units. It is extremely important.

What has occurred in this case highlights how the procedures that were clearly set out were not followed. Organs of children who had died were retained in a mortuary for a long number of months. As I said, retention of organs should be for a temporary period only. In this case, they were retained for a long period and then sent for incineration. There are many questions to be answered and it is in everyone's interest that they be answered as fast as possible.

See this speech in context