Sarah Jane Byrne went to Portlaoise three times in the space of one week in 20O9 - she was 37 weeks into her third pregnancy - her first attending Portlaoise's maternity unit.
On her first visit she was told that she neeeded to be induced because the baby had not developed to a point expected for 38 weeks.
She was admitted by a consultant. However, in the maternity unit she was seen by a locum consultant. Sarah says that doctor decided to discharge her saying there was no cause for concern.
She was not advised to return until she went into labour. Within a week Sarah says she knew her baby had died, because there was no sign of movement.
She went to the hospital in the middle of the night and it was confirmed that her baby had passed away.
Sarah, who lives in Kildangan with husband Keith, asked staff to be induced. Her request was declined and she was sent home and told to wait until she went into labour.
Two days later she was back in Portlaoise after a visit to her GP. She could not bear the idea of carrying a dead baby around for a number of weeks. Her child Millie was delivered as a stillbirth on her third visit in seven days.
“She was stillborn at 38 weeks and we believed her death could have been prevented,” Sarah told the Leinster Express last week.
Sarah and her husband knew that there were problems but did not realise that their child could have been saved until the RTÉ Primetime programme in 2014.
They were one of the first familes to make a complaint. But they also went to a third party in the UK for a full report on the delivery.
This report confirmed that she should have been induced when she was first admitted.
Some eight years after losing her child, Sarah remains angry, in particular with the HSE. She believes the report published last week lacks the human stories which would bring home to people the mistakes made in Portlaoise.
“As a mother who completed the horrendous review process with the HSE over the death of my baby girl in Portlaoise hospital in 2009, I am only cautiously hopeful that the HSE will put these recommendations in place and really treat parents with more sympathy over the circumstances of their babies deaths”, she told the Leinster Express.
Sarah and her husband reached a legal settlement with the HSE last year over her baby girl's death.
“The legal case itself was not as harrowing as trying to deal with the HSE during the reviews, and it was very much a case of he said/she said and you just got nowhere with them in the end,” she stated.
A full systems review was carried out. This is claimed to be the gold standard when it comes to getting answers when things go wrong in hospitals. Sarah does not believe it revealed the truth and believes that people involved in her care did not tell the full story about their role or what happened.
“They refused to admit to me in their review that they made mistakes, yet I had an independent review into my case from the UK which completed contradicted what my report stated.
“We cried tears of relief and complete sadness when we read our independent report from the UK and it was such a contradictory read from what the HSE were telling me.
“We settled the case legally because it's just something that you do to get on with your lives, but as far as HSE reviews go, it did not inspire confidence that we can trust them,” she said.
Sarah highlights several instances of what could be described at the very least as “inconsistencies” in the outcome.
She says the named consultant in her care claimed at one point that she was not his patient. She claims the doctor who admitted her for inducing denied doing so.
She says a doctor on the inpendent HSE commissioned review of her case stood over the decision to discharge without induction, but admitted that he would have called her back within two days to check her baby's health.
She was also told incorrectly at one time that a hypoxia or lack of oxygen was not the cause of her child's death, when it ultimately proved to be.
Sarah believes that the complaints review process was overly concerned with the reputation rather than getting the full truth.
She believes that the review published last week should have carried more details on individual cases. The lack of such stories means there is no humanity in the report.
Sarah did go back to Portlaoise in 2010 to have a fourth child. Her two other children were born in the Coombe, before the family moved to Kildangan from Dublin.
She did not have the deatils of what went wrong in Millie's case when she returned to Portlaoise. Had she known, she said she would have gone elsewhere.
She said she was treated 'like royalty' when she returned which, in itself, raised suspicions about how her previous pregnancy was handled.
Sarah said there were many good and kind staff at the maternity unit in Portlaoise. Her ultimate grievance is with the HSE whom she has no trust in both for how her pregnancy was handled, and how the investigation proceeded afterwards.
She paid tribute to Patient Focus, in particular its acting chief executive, Brigid Doherty who accompanied her on every step of the journey she took to get justice for Millie.
“Thank god for Brigid Doherty and my independent review (from the UK) which empowered myself and my husband to fight, otherwise we would have just accepted their verdict that nothing was wrong and my baby girl was just not meant for this world. The whole review process was just as upsetting for us as when we first lost our baby because we just couldn't get the truth out of them,” concludes Sarah.