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TheIrish Health Service Executive (HSE) has apologized to 24 women who were wrongly told they had suffered a miscarriage.
Two of the women went on to suffer miscarriages after a medical procedure to remove the fetus, the remaining 22 women went on to give birth.
The National Miscarriage Misdiagnosis Review launched an inquiry in June 2010 when Dubliner Melissa Redmond revealed that she gave birth to a baby boy, after she has been informed that she had miscarried.
Redmond has been instructed to undergo a procedure known as dilation and curettage, which is normally carried out after a miscarriage.
Speaking about the error, Dr Philip Crowley, the national director of quality, risk, and clinical care with the HSE, said: “The HSE would like to sincerely apologize to the women involved, and their families, for the shortcomings in care provided to them and for the distress that this will have caused them.”
The review concluded that inadequate staff training and over-reliance on ultrasound equipment led to the 24 women being misinformed about their pregnancies.
It showed that consultants and registrars accounted for 79 percent of health professionals who made the false diagnoses.
The review also found the following:
Medication to aid the miscarriage of a foetus was prescribed to eight women.
Six women underwent an operative procedure.
Formal training in early pregnancy ultrasound was reported by only three of the clinicians who made an initial diagnosis.
In 12 cases there was no mandatory training in ultrasound within the hospital at the time the case occurred.
Eight hospitals did not have an early pregnancy assessment unit at the time of the diagnoses.
In six cases the scanning machine was more than five years old.
The chairman of the review said that the misdiagnoses all occurred at the early stages of pregnancy, when ultrasound diagnosis alone is unreliable due to the undeveloped fetus.
“Over-reliance on ultrasound to diagnose a miscarriage in very early pregnancy has been repeatedly highlighted since the introduction of the technique in the 1970s and we have made recommendations that caution against the use of ultrasound alone to detect a pregnancy before eight weeks gestation,” he said.
The HSE revealed that hundreds of concerned women called helplines in maternity hospitals when the scandal broke last year.