The cremation of dead babies’ organs in the maternity ward of Cork University Hospital (CUH) without the families’ permission was “a misguided decision and a departure from local policy and national standards,” according to a report.
The review came after it was revealed that the babies’ organs were burned without the knowledge of 18 families.
It revealed that the organs were burned in Denmark by a private company. The South/South West Hospital Group (SSWHG), CUH and Cork University Maternity Hospital (CUMH) have issued another apology to the families affected today.
Perinatal organs retained at the hospital after autopsy were cremated twice instead of being buried or cremated as agreed with the families. This happened in 2020 during the first wave of Covid-19.
The review found the decision to cremate the organs was made after unresolved efforts to find a place for the burial and the autopsy team struggling with “unanticipated and unanticipated strains of the Covid-19 pandemic.” would have.
In March 2020, the HSE Estates Department had warned of the possibility of “mass casualties” and the need to increase morgue space.
The system analysis report was shared with affected families and released today.
SSWHG, CUH and CUMH fully accept the findings of the report prepared by an external review team.
“SSWHG deeply regrets that this troubling incident took place and acknowledges that a mistake was made and sincerely regrets the additional hardship this has caused the grieving families,” they said.
“The CEO of CUH commissioned the systems analysis review after the incident was brought to the attention of hospital management as the actions taken were not consistent with established systems and processes at CUH for the respectful disposal of the perinatal organs, despite the unprecedented context of Covid 19. It also did not meet local guidelines and national standards.
“It was found that 18 couples, bereaved parents, had previously given the hospital permission to make arrangements for the retained organs after autopsy and had a clear expectation that those arrangements would apply to burial or cremation.
“The Serious Incident Management Team (SIMT) has determined that all affected parents will be contacted and a review conducted with external subject matter experts in accordance with the Health Service Executive’s (HSE) disclosure policy.”
The hospital group said the initial focus will be “to be open and transparent about what happened and to apologize to the bereaved parents.” All contacts with the affected families were made on May 11th and 12th, 2020. Although the error occurred at CUH, CUH recognized that this situation would be deeply distressing, CUMH has volunteered to take the lead in open disclosure and has continued to support parents with the expertise of the Bereavement and Pregnancy Loss team.”
The outside team of experts established the circumstances leading to the incident in which the perinatal organs preserved after the post-mortem were sent to be burned instead of being buried or cremated. These measures took place in the first wave of the Covid-19 pandemic, as hospitals across the country prepared to significantly increase their cadaveric capacities for mass deaths.
This incident is limited to perinatal organs stored at the CUH morgue between May 2019 and March 2020. All CUH records were reviewed and assured that no other families could have been affected by this incident. All other perinatal organs stored before and since April 2, 2020 and for hospital treatment have been correctly treated.
While the system analysis review was underway, CUH made the decision to implement changes immediately. A number of measures have already been taken to reduce the likelihood of such an incident happening again.
The support of the CUMH Bereavement and Pregnancy Loss team remains in place to provide ongoing contact, care and support to parents as needed. This was provided not only because of the incident, but also in recognition of the impact of the delay in the verification process. Families have been assigned a key contact for the upcoming weekend and engagement will continue to be offered.
CUH said it accepts the report’s findings, prepared by the external expert review team, and is committed to fully implementing the recommendations.
“It is important to highlight the change brought about by the Perinatal Pathology Working Group, augmented by dedicated professionals, described in the Impact section of the report. Work on recommendations 1, 3 and 5 has already started. It is intended that all local recommendations will be implemented by Q1 2023,” it said.
“SSWHG, CUH and CUMH would like to once again apologize to the 18 families affected and deeply regret that this worrying incident has taken place.
“When conducting the systems analysis review, all 18 families were contacted and invited to a meeting with the review team. Six of the 18 families accepted the offer. Three of the six families who accepted the offer submitted questions for the team to review.”
CUH said that after review and contrary to what had been outlined in the terms of reference, the review team made the decision to share the final report rather than sharing a draft with families involved in the process. This was primarily to avoid further delays for the families.
“The primary purpose of sharing a report at the draft stage is to verify the factual accuracy of specific and identifiable contributions to the report,” the hospital said. “However, the fact-checking process involving staff involved had led to a significant delay in a report that was long overdue.
“Furthermore, only a few of the affected families have directed comments or questions to the review team. These posts provided context, an understanding of the implications for them, and a useful list of questions these families wanted to ensure the review was answered. However, the review team considered that they did not change or question the facts or inform the root cause analysis in this particular incident.”
https://www.independent.ie/irish-news/incineration-of-babies-organs-was-a-misguided-decision-and-deviation-from-standards-review-finds-42173543.html Cremation of baby organs was a “misguided decision and a departure from standards,” according to the review