Portlaoise hospital staff who did not raise the alarm over babies' deaths should lose their jobs, says bereaved mother Shauna Keyes.
“To be fair, management were not the ones who allowed children to die, or covered it up. What about the coroner, the staff in the hospital? A lot of people should be responsible,” Ms Keyes told the Leinster Express last week.
Last Wednesday the HSE published a report on the Systems Analysis Review into the death of baby Joshua, which happened in 2009.
“The HSE and the Midland Regional Hospital at Portlaoise would like to reiterate its unreserved apology to Shauna and Joseph for the failings that resulted in the death of baby Joshua and for the levels of distress caused as a consequence of the prolonged nature of the process ,” the HSE said last Wednesday January 20.
The report was made public at the request of Joshua's parents. It found “significant failings” into the care of Joshua. The HSE said that its 23 recommendations have been put in place in Portlaoise's maternity unit.
While welcoming the improvements, which include the increase of maternity nurses from 39 to 70, Ms Keyes is not happy that there have been no public sanctions of HSE staff.
“Unfortunately the worst that can happen for a doctor is to be struck off. At the moment the biggest thing they have faced is the public shame, but people should lose their jobs,” she said.
She does not blame all staff in the hospital.
“Some people just didn't have the training, and others couldn't ask for help because they were afraid to, or they were ignored,” she said, also condemning the local staff for not investigating mistakes or informing management.
She is now convinced of the safety of the unit, so much so that she returned for the birth of her second child, Maisie-Ann, born safely in December 2014.
“It is six years and three months since Joshua died. At last now people can have confidence in the maternity unit. There has been some great changes. Our family have spent so much time calling for improvements, I am very impressed now, it is very good, staff are happier and patients feel safer,” she said.
She believes the changes are permanent.
“I don't think staff will be dropping standards. People want to say they are proud of their hospital. They have been given the facilities and the training now,” she says.
Making the report public has helped them to grieve.
“It was closure. It is one thing to know the truth yourself, but to see it on HSE paper is on a totally different level. We are very happy it has come this far,” she said.
She also welcomes national legislation underway.
“A new national maternity strategy is before the Cabinet. The law must change to burden clinicians with a legal obligation to inform patients of errors. In time, this will restore trust,” she said.
It has been a long battle.
After Joshua's death in 2009, she was given a six page 'incident report form' to fill in, and heard no more.
The HSE did conduct an investigation into her son's death two years on, along with two other babies' deaths. However they did not inform the families involved.
“Nobody cared as long as no questions were asked,” Ms Keyes said.
It was only two years ago, when bereaved parent Roisin Molloy heard her on the radio fundraising for a 'cold cot' to give parents more time to mourn deceased babies, that Ms Keyes learned hers was not the only “incident”.
Later that year, after they hired a solicitor, Joshua's inquest was finally heard.
“A mere three years and 11 months after his death. I and Joshua’s dad had begged and begged for this day to come. We just wanted to know the cause of death and the permission to receive a death certificate,” said Ms Keyes.
A month later, she agreed to contact RTE's Primetime to highlight the scandal.
“This seemed to be the only thing to do because nobody was listening to us. We were hurt, frustrated and exhausted. After the programme, we didn’t need to contact the HSE or the Department of Health. They came to us. Unwittingly, our babies became the impetus for change,” Ms Keyes said.
Now she continues her work, as a volunteer with the support group Patient Focus, for people damaged by the healthcare system.
“I was 18 when Joshua was born and because of his death I never made it to college. I had to teach myself all the medical terms, and now I can do something I love, helping other people through this process, to pick up the pieces. We are grossly underfunded by the HSE, and it can be very difficult to hear people's stories. There are a lot of people still left with no answers,” Ms Keyes said.