An investigation has found that the organs of 18 babies were sent from Cork University Hospital for incineration abroad alongside adult body parts without the consent or knowledge of their bereaved parents, because of a "misguided" decision and a deviation from local policy and national standards.
The report, which was today shared with affected families, also found the decision to send the babies' organs for incineration was made by the hospital's post-mortem room team.
The team had consulted guidelines specific to waste management, but these were not, the investigation stated, compliant with the sensitive disposal of organs.
The report described the decision to send the organs abroad for incineration as "misguided". It said the post-mortem room team stated that they very much regret the actions taken.
The report also stated that a national audit has confirmed that what happened was an isolated incident at Cork University Hospital and had occurred "due to severe pressure on the post-mortem room team in unprecedented circumstances in preparation for the Covid 19 pandemic".
The 18 families involved were initially contacted by Cork University Maternity Hospital in May 2020 to inform them that the organs of their deceased babies had been incinerated in late March and early April of that year.
The report said Cork University Hospital subsequently wrote to the 18 families involved again after RTÉ Investigates revealed details of the investigation on Prime Time in September 2021.
The hospital offered an apology from Cork University Hospital and Cork University Maternity Hospital for the error and acknowledged that a serious mistake was made.
The investigation was commissioned by the executive management board of the hospital.
The review team's report was delivered to the families involved this morning.
The review team acknowledged the distress experienced by the bereaved parents, and the team said it sincerely apologised for the impact that both the incident and the delay in completing the report had on them.
The review team also acknowledged that Cork University Hospital, Cork University Maternity Hospital and the South-SouthWest Hospital Group had also apologised to the parents affected.
The findings come two-and-a-half years after the incinerations first came to the attention of hospital management.
Affected families had initially been told the review would be completed by November 2021, but it has been subject to repeated delays.
It had originally been thought that the organs were sent for incineration to Antwerp in Belgium in March and April of 2020, along with adult body parts from the hospital.
However, the report has established that the organs were, in fact, incinerated by an approved contractor in Denmark.
The report said that in December 2019, the hospital was informed that its plot for the burial of perinatal organs at St Mary's Cemetery, Curraghkippane, in Cork, was full.
As a result, the organs of a number of babies that had been released by the pathology department following post-mortem examinations lay in storage in the hospital morgue, in some cases for several months.
The report said that by March 2020, the post-mortem room team was dealing with "the unexpected and unanticipated pressure of the Covid-19 pandemic".
It detailed efforts made by the post-mortem room team to identify an alternative burial site for perinatal organs from Cork University Hospital but, despite these efforts, an alternative burial site for the hospital was not identified.
It said predictions for the hospital and city were that extreme measures were required to increase mortuary capacity in response to the Covid-19 pandemic.
A decision was taken by the team to dispose of the perinatal organs through incineration.
The report does not specifically say who took the decision to dispose of the perinatal organs through incineration.
HSE standards state that, when organs are retained for further examination following a post-mortem, hospitals should support the next-of-kin by facilitating their return or arranging their sensitive disposal by burial or cremation only.
Six of the 18 families affected by the incinerations accepted an offer to meet the review team.
They outlined that the telephones calls received in May 2020, did not convey to them the details of the events that occurred in that the word incineration was not mentioned. For one family, English is not their first language and they did not understand the nature of the call.
Three families told the review team they did not get subsequent follow-up letters offering meetings with the hospital, while some complained the letters received were vague.
The report said all six families lacked full understanding that their babies' perinatal organs had been incorrectly sent for incineration. They did not realise the scale of what had occurred until the RTÉ Investigates broadcast on Prime Time in September 2021.
In response, the report said, the hospital staff who made the calls outlined that it would have been their preference to have had face-to-face meetings to openly disclose in person what had occurred. However, this was not possible due to Covid restrictions.
The review acknowledged that there was an element of personal burden and stress that staff would have felt in relation to all the reported predictions at this time regarding Covid-19.
However, the report said , the post-mortem room team did not escalate this prior to sending the perinatal organs for incineration.
The report has made several recommendations on the implementation and auditing of defined quality standards.
It said all local policies should be revised to ensure the correct disposal of organs at Cork University Hospital. It also recommended that the HSE nationally should update its Healthcare Risk Waste Management Guidelines.
The report said there was no direct engagement and communication with other staff members within the pathology department, prior to the decision to incinerate the perinatal organs on 25 March and 2 April 2020. It said the decision was taken at local level in the post-mortem room, and there was no consultation outside of the post-mortem room.
The report said new consent forms for both consented post-mortems and for post-mortems directed by a coroner have been introduced at all maternity sites across the South-SouthWest Hospital Group.
It also said the perinatal pathology service has been "taken over" by the perinatal pathologists and their team of medical scientists since April 2021.
They now ensure that Cork University Hospital retains, stores and disposes of organs in accordance with national standards and local policy.
Additional reporting: Paschal Sheehy