The HSE Maternity Clinical Complaints Review has said that for many of the complainants, compassion, sensitivity and understanding in the provision of expert clinical care was not always demonstrated.

The review received 203 complaints covering events over 40 years.

The report said that the length of time it took to complete the process has been hard for participants, especially for those who lost a baby.

There were 50 patients who did not consent to a review of their case.

The 63-page review report says that the complaints have led to improvements in maternity services in Ireland.

Most of the complaints relate to the Midland Regional Hospital Portlaoise and others involve the Rotunda and Coombe hospitals in Dublin, Limerick University Hospital, Cork Maternity Hospital, Kerry General, the Midland Regional Mullingar, the Midland Regional Tullamore and Galway University Hospital.

The complaints reviewed related to perinatal death, maternal death, communication, access to information, autism, gynaecology issues, health care record issues, infant after care and management of labour.

The report says the external expert clinical reviewers attributed perinatal deaths to a range of causes, occurring in multiple different circumstances.

It said that specific conclusions cannot be drawn in this context.

The review covered three phases.

Phase one only involved a review of the health record. Phase two involved an initial screening review and individual meetings with families.

Phase three involved an examination of CTGs - cardiotocographs at Portlaoise - which involved grossly abnormal recordings of the baby's heartbeat which had not been acted on.

These cases involved four perinatal baby deaths, one of which only came to the attention of the team during the review.

The review looked at CTGs at Portlaoise from the mid 1980s to 2014 to see if there was a pattern.

It found 90 cases of perinatal deaths at Portlaoise.

However, no evidence of any similar failure to react to pathological CTGs, that might have been a contributory factor in these outcomes, was identified.

Minister, patient group and doctors react to report

Minister for Health Simon Harris welcomed the publication of the report but said: "It is regretted that it has taken such a long time for these issues to have full visibility.

"The number of these complaints over such a long period of time is a wake-up call to all of us to ensure our health system becomes more open, and deploys systems that are responsive and listen and learn from patients".

The minister continued: "Importantly, I have also been assured by the HSE in relation to the safety of maternity services in Portlaoise Hospital today.

"I would also recall that HIQA's most recent report on Portlaoise, published last December, confirmed the high standard of care being delivered by the maternity unit. It also heartening to see that the recommendations arising from this review have in many cases already been implemented, while the HSE is actively progressing others".  

National patient advocacy organisation Patient Focus said that during the protracted process, some families were pushed beyond endurance.

The organisation said it was concerned that the HSE had been unable to conduct a timely review that met the needs of patients and families and the process was ad hoc.

It said that it was very difficult for families to feel a sense of inclusion and confidence that their concerns mattered.

Patient Focus, which was a participant in the review' said that women and their families should have been offered access to a written medical review of their case.

It said it was first approached in the Spring of 2012 by the grieving family of baby Mark Molloy.

The family had expressed alarm at the care provided in Portlaoise.

Patient Focus said that phase three of the review involved a historical look back, to establish if any further unreported major incidents existed and "thankfully nothing was found".

Dr Susan O'Reilly, Chief Executive of the Dublin Midlands Hospital Group, said she wanted to acknowledge it was a difficult and stressful process for the patients and their families.

She apologised for the time it took and said patients felt they had not been listened to in the past.

Dr O'Reilly said the HSE had learned from what had happened and said the complaints were screened to see if there were any adverse events.

Dr O'Reilly admitted there had been a "wobbly start" to the review.

She said it was not a full systems review.

Dr Peter Boylan, who was involved in the review, said 31 of the 203 cases related to complaints about baby deaths.

Dr Peter McKenna, another member of the review, said the latest evidence is that Portlaoise operates within the parameters of what is statistically acceptable regarding perinatal mortality.

He also said that no maternity hospital lies outside the range of what is acceptable.