One of the authors of a report into the care of 18 babies and their mothers at Portiuncula Hospital has said a combination of resource and staffing inadequacies led to a number of failures, including the serious harm and death of babies.
Professor James Walker discussed some of the findings of the Clinical Review of Maternity Services at the hosptial in Ballinasloe, Co Galway between 2008 and 2014 on RTɒs Morning Ireland.
Prof Walker said a lack of staff at midwifery level and consultant level was key to many of the problems.
He said that "as soon as things go well you can cope ... but when things go wrong" there were not enough people around to assist.
He said that big reviews were not the way to solve these problems, they should be solved at a local level.
Prof Walker said that the report followed concerns raised by a number of families.
However, he said that in many ways if there had been due diligence or open disclosure at the time of the incidents involved then this report would not have happened.
He said the report "really is a reflection of the problem of not talking to people, not investigating and not accepting that errors have been made and they can improve."
He criticised the lack of an open disclosure approach to care in some cases - including a situation where a C-Section was carried out after the baby had died.
He said this was done without consultation with the mother and when a senior doctor was not available.
Prof Walker said training and background training for younger doctors was inadequate.
He said that individuals did not upskill or train to keep skills up and the infrastructure was not there to investigate things that go wrong and to learn from them.
He said the lack of a liaison or bereavement midwife to talk to families whose babies had been transferred to other hospitals also led to a breakdown in communication.
He said without the opportunity to train doctors in hospital teams - and teach staff how to escalate problems and talk to people - the hospital instead had a system that when under stress tends to break down.
Prof Walker said that no one thing or one person was to blame for the failures but rather it was a system failure that they did not have the right people in place.
Prof Walker said changes have been made and Portiuncula Hospital now has a senior midwife in the labour ward at all times.
He said there is also now have a consultant in obstetrics full time to assist and to teach each day.
A solicitor specialising in medical negligence who represents a family of one of the babies left with injuries and disability after being delivered in the Portiuncula said the findings of a clinical review were bittersweet for his client.
Michael Boylan said the clinical review left the baby's mother feeling vindicated and justified in her complaint, but also having received such unsatisfactory experience.
He said the hospital would not deal with her or investigate her complaint and it was only when the mother phoned the hospital helpline in response to this inquiry that she got any honest answers.
Mr Boylan said that his client's child suffered disability as a result of clinical failings at the hospital including a failure to recognise foetal distress, incorrect reading of ECG's and a failure to intervene by Caesaerean section earlier.
Mr Boylan told Morning Ireland
that the family's experience in relation to open disclosure was not satisfactory.