The mother of a baby boy who died during labour at Portlaoise Hospital in 2018 has called for a national inquiry into the deaths of Mothers and babies and injuries suffered by newborns in maternity units.
A verdict of Medical Misadventure was recorded at the 2022 Inquest into the death of baby Luke Duffy, who was tragically delivered stillborn on the 30th October 2018 at the Midlands Regional Hospital in Portlaoise.
Luke’s death was officially recorded as an intrapartum death, which is when a baby dies after the onset of labour but before they are born.
Initially, Ms Duffy claims she was told that her baby’s death was unexplained by a doctor/midwife, and was just “one of those unfortunate events,” which led her to look for answers through multiple inquiries.
An inquest held into his death, started with the Hospital Manager Michael Knowles apology letter been read out stating: “I wish to express our sincere apologies for the failings in care and ultimate death of your son, Baby Luke, on 30th October 2018.
“The hospital accepts this should not have happened and sincerely regrets the tragic consequences to baby Luke, you his parents and to your extended family.”
The infant died despite his mother, Lisa Duffy, pleading with staff to induce his birth early in the three days before her son was born. In addition, she claims that she was not examined by a consultant for six days before her son’s death, despite the fact it was a high-risk pregnancy.
The 2022 inquest heard that the hospital’s maternity unit was very busy over the bank holiday weekend, with all available slots for inducing the baby booked up until 6pm on October 29th, the day baby Luke died.
Ms Duffy has since set up campaign group Safer Births Ireland, which is now demanding a national independent maternity-commissioned inquiry to take place in Ireland. She says the tragedy she and her family suffered has been exacerbated by an investigative process which she believes was “unfair” and as well as lacking transparency, she does not know if anybody was ever held to account for what happened.
An active petition set up by Safer Births Ireland has 1098 signatures.
Speaking to Gript, Lisa said that she set up the campaign group to advocate for change, and because she believes her baby’s death was avoidable and preventable.
“Three years after Luke’s death, we had his inquest. We came out of the inquest really, genuinely believing that babies’ lives would be saved because of sharing our story.
“However, we were then told by the Coroner that there would be no guarantee that the recommendations made during the inquest would actually be implemented by the HSE,” she said.
“Since there is no statutory body in place to instil these Coroner’s recommendations, I just thought, what sort of country are we living in?
“I just couldn’t understand it, or the fact that more babies could die because there is no statutory body in place to confirm that those recommendations – which the coroner has confirmed are the cause of death – would ever be implemented to prevent the same failures in care reoccurring.”
“As bereaved mothers, we came together to try and get the government to listen to us, and to try and change legislation to protect mothers and babies,” Lisa said. So far, more than 20 mothers have joined the call for an inquiry, which is set to be made formally in the Dail in the coming weeks.
“History will continue to repeat itself,” she said, “Unless legislation is implemented to protect mothers and babies.”
Luke Duffy passed away on October 29th 2018, a bank holiday Monday, after suffering acute hypoxia, the coroner found.
It was Ms Duffy’s first pregnancy, which saw her suffer from gestational diabetes.
But when it came to the induction she was initially due to be induced in the week leading up to October 26th, 2018, however this was changed. The induction was then set for the 29th October.
“The date was set, but I went into the hospital with labour pains in my back on Friday the 26th October. I was told that it was the start of labour after a vaginal examination.
“I was kept there that entire weekend, and my blood pressure was increasing, hypertension and potentially signs of preeclampsia. I continued getting back only contractions, but I was told , ‘That’s only the start [of labour].”
“I complained that the progress of the labour was not being checked, and in addition to that, an ultrasound and a vaginal examination was not done – despite my gestational diabetes. I believe there was a ‘wait and see’ approach.”
“Every day over that weekend, I would ask the doctor in charge: Can we do the induction today? Why are we waiting? But I was repeatedly told, “No, we are waiting, we are sticking to the planned Induction date of 6pm on 29th October.”
The staff said they were sticking to the original plan to induce Ms Duffy on the 29th October, but Ms Duffy, who was exhausted, began to worry about how she would push the baby out as she was so tired.
There was no internal examination carried out because, according to Ms Duffy, she was told she would only get an infection and because she was not experiencing any abdominal pains, her baby was not ready to come out.
“It was all to the detriment. Luke paid the ultimate price, with his little life lost. For me, when the 29th October finally came, I was in chronic pain with my back. The staff told me they would finally start the labour – even though I knew I had been in labour over the course of those last couple of days. It was harrowing.”
An ultrasound was finally performed on the Monday, and after three days of asking to be induced – which tragically revealed that baby Luke had died.
“At that stage, an ultrasound was finally performed.
“I was then told to head home, and the hospital rang my husband to tell him separately. We weren’t even told together. It was just appalling from start to finish.
“I just could not believe, having endured what I had, that the worst living nightmare was still to come when the hospital said they wanted to send me home, even though I was still contracting in my back and in that level of pain.”
Three hours later, she says, an examination of the cervix was finally done, revealing she was in labour, and was 4 cm dilated.
The bereaved mother and campaigner says while there is a “culture of silence” around preventable baby deaths, they do continue to happen, with a number of women reaching out to her to share their stories.
“There is a fear of speaking out, but that needs to stop. Legislation has to be passed to protect mothers and babies, or else we will continue to see these tragedies happen.”
She says that there have been no repercussions for the staff involved, something which she believes needs to change. “Those whose decisions meant that my son was not delivered alive continue to be able to practise. There are no repercussions despite the damning results of the inquest.
“This does not make sense to me – because staff involved in these tragic cases can continue to practise in other hospitals and jurisdictions and potentially cause harm there.”
Michael Knowles, general manager of the Midland Regional Hospital Portlaoise, expressed the hospital’s “sincere apologies” for failings in the care given to baby Luke, adding that it would “everything possible” to ensure they did not happen again.
The inquest heard the doctor on duty at the time was unavailable to give evidence to the inquest on Monday, a situation the coroner described as “unsatisfactory”.
“Sadly, these are day to day problems happening in maternity units across the country,” Ms Duffy told Gript. The mother says that her organisation is aware of 42 preventable baby deaths.
“That’s us, as bereaved mothers trying to advocate for change, having to do a Google search. Because there is no available database right now. Why does the government not have these statistics readily available?
“Right now that doesn’t exist, and we feel that is unacceptable. As an advocacy group, we would urge any parent who has suffered the death of a baby or partner, or has had a baby injured during labour, to contact us.” Our email address is saferbirthsirelandalliance@gmail.com
“Enough is enough,” the co-founder of Safer Births Ireland says. “Mothers and babies are still dying, and babies are being injured.”
There is a lack of open disclosure, Ms Duffy said. “It took three and a half years for me to get answers. You can imagine the mental distress and torture we went through. The process of getting answers, and the cover-up and lack of accountability, is just soul destroying.”
She believes there could be more mothers out there whose babies have died due to medical misadventure – who have been told that the hospital in question was not at fault, just as she was initially told.
“When you are that low in your grief, it is almost impossible to search for answers. But if my story resonates with any other mother who has suffered a loss like this, we would urge them to get in touch with us.”
“I only started to get answers when I accessed my medical chart through a Freedom of Information request, and I could clearly see there were issues.
“But grieving mothers should not have to go to these lengths. This accountability and access to these answers needs to be embedded in law, or else I fear history will continue to repeat itself.”
“We cannot allow more lives to be lost or damaged,” Ms Duffy said.
“We need immediate action from our government for a National Independent Maternity Commissioned Inquiry in Ireland.”
You can read more about the Safer Births Ireland campaign here.