Warning signs were missed and there had been a series of communication failings in a labour ward in the hours before a baby suffered catastrophic brain damage during birth.
Dr John Bermingham, a cosultant obstetrician gynaecologist at University Hospital Waterford (UHW), told Cork City Coroner’s Court yesterday while he was not on duty on October 17 last year, when first-time mother Krystle Hunt presented at the ward, it was clear to him she was not attended to properly by the on-call registrar.
When she presented at 11pm, Ms Hunt had sepsis, a strep B infection — present in 25% of all pregnancies — and a raised temperature. But it was 6.30am the next day before she was rushed to theatre for an emergency C-Section.
Baby Eli had to be resuscitated and was transferred in a critical condition to Cork University Maternity Hospital (CUMH) where he died 13 days later, on October 31.
Dr Peter Kelehan, who performed an autopsy, said the cause of death was brain damage due to an inflammatory response due to ascending amniotic fluid infection arising from the group B streptoccocal infection.
He said it was clear to him baby Eli should have been delivered up to six or seven hours earlier. He said the presence of a patient in labour with an elevated temperature should have been a clear warning that delivery be expedited.
But he said the presence of strep B should have added to those warnings.
“There were a lot of failings here, chiefly in communications. But there was a failure to attend to the patient which is what every registrar is expected to do,” he said.
“Something like this is rare, but tragic, and is often down to a series of missed opportunities. It is not down to one simple error — it is usually compounded by a series of missed opportunities. But, by the time delivery was recognised as needed, things had deteriorated.”
The jury returned a verdict of medical misadventure and welcomed planned new protocols.
Afterwards, Ms Hunt welcomed the verdict: “It won’t bring our baby back but we are Eli’s voice now.
“All we ever wanted as parents was for Eli to arrive safe, and healthy.
“I can only hope that lessons will be learned from this and the recommendations be implemented as a matter of urgency.
“I hope this will avoid future unnecessary baby deaths and will save other families going through the heartache we have suffered.
“Eli is our first baby and he will always be part of our lives. We are devastated and will never be the same again.”
In a statement, UHW and the HSE issued an apology to the Hunts for the standard of care which was provided that night.
They acknowledged the experience has been devastating for them and has had a profound effect on them, and they said they are committed to implementing the recommendations quickly.
By Eoin English
Irish Examiner Reporter