It appears clear that the lessons of the breast cancer controversy in 2007 were not learned at Portlaoise, or the health service, because nobody had the full picture of safety problems at the maternity unit.
The chief medical officer said there was ‘weak’ governance in 2007 and, similar to the maternity service scandal, there was no awareness of the number of adverse incidents until there was an outside review.
“One of the core findings of this report was that the full picture as it relates to safety over the period in question (06-14) was not apparent to anyone,” said the report.
However, Dr Holohan concluded that “many organisations” had enought information on birth rates, adverse events, legal claims to act earlier.
“While there was an awarness that the service was under pressure, there does not appear to be any evidence that monitoring of how this might have been impacting on patient care was taking place,” said the report.