A Cork mother affected by the organ incineration scandal has said it was an “emotional day” to receive the findings of a report into how the organs of 18 babies, including one of her twin boys, were sent for incineration overseas without the knowledge or consent of bereaved parents and said that families deserved the information contained in the report “a long time ago”.

The organs of the 18 babies were initially stored in the morgue at Cork University Hospital (CUH) following post-mortem examinations and were later sent abroad for incineration on two occasions in March and April of 2020 instead of burial or cremation.

The organs were sent for incineration along with a number of adult body parts.

Families affected were yesterday furnished with a long-awaited Systems Analysis Report on the circumstances leading to the incineration of the organs without the parents’ consent or knowledge.

In a statement, the South/South West Hospital Group, CUH and Cork University Maternity Hospital (CUMH) said they “fully accept the findings” of the report undertaken by an external expert review team.

“The South/South West Hospital Group deeply regrets that this distressing incident occurred and acknowledges that an error was made, and is truly sorry for the additional distress this has caused to grieving families,” the statement continued.

It said that the actions occurred “in the first wave of the Covid-19 pandemic when hospitals nationwide were preparing to significantly increase their mortuary capacity for mass fatalities” and that all “CUH records have been checked and assurances have been provided that there is no possibility that this incident has affected any other families”.

“All other perinatal organs retained prior to and since 2nd April, 2020, and for hospital arrangements have been dealt with correctly,” it added.

It also said that a number of steps have already been taken “to reduce the likelihood than an incident of this type can occur again”.

The review, the statement said, was commissioned by the CEO of CUH after “the incident was brought to the attention of hospital management” as the action taken is “not in keeping with the established systems and processes in CUH for the respectful disposal of perinatal organs”.

The statement said that it was established that the bereaved parents “had given prior permission for the hospital to make arrangements for the retained organs following post mortem, and had a clear expectation that these arrangements would be for burial or cremation”.

It said that families were made aware of what happened on May 11 and 12, 2020 adding: “Although the error occurred in CUH, recognising that this situation would be deeply distressing, CUMH volunteered to take the lead role in the open disclosure and has continued to support the parents with the expertise of its bereavement and pregnancy loss team.”

The published Systems Analysis Report, a 124-page document, states in summary that the review team concluded that the incineration of the organs was “a misguided decision and a deviation from local policy and national standards”.

“The post-mortem room team have stated that they very much regret the actions taken.

“It was confirmed by the National Audit in relation to compliance in respect of the Standards and Recommended Practice for Post Mortem Examination Services, HSE 2012, that this was an isolated incident in CUH,” the review team added.

The report outlines a number of local recommendations and a national recommendation which CUH says it is committed to implementing in full.

Families received the report 

Speaking to The Echo, Leona Bermingham, the mother of one of the babies, said it was an “emotional day” receiving the report yesterday.

Ms Bermingham and her partner Glenn Callanan were the first of the 18 families to go public about the scandal.

Their son, Lee, died hours after Leona had given birth to him and his twin brother, Lewis, by emergency C-section.

She cited a number of findings in the report which she found challenging to learn.

Amongst them was a line in the report which states that “on the dates the perinatal organs were sent for incineration an approved contractor in Denmark was used” as previously she had been informed that the organs had been sent to Belgium.

“I think we deserved to know a long time ago and we shouldn’t have had to wait till this report was finalised,” Ms Bermingham said.

She said that she had been of the belief that CUH had been issued with a directive to clear out the morgue, which, while the review team stated that there were multiple documents outlining planning for mass fatalities during the pandemic, the team is “unaware of a directive to clear out the morgue”.

Ms Bermingham had also previously expressed upset that families had to wait for the final report and were not initially issued with a draft copy as had been promised.

A spokesperson for CUH told The Echo that support remains available to the affected families as does “the hospitals willingness to explain any element of the Systems Analysis Report”.