The parents of a baby who died 10 days after being born at Cork University Maternity Hospital have told an inquest that her death could have been avoided if the hospital had stricter protocols and policies on how to respond to abnormal heartbeats detected in a baby before delivery.
Christina and Kevin Neiland from Pearse Road in Ballyphehane in Cork told a sitting of Dublin District Coroner’s Court that they believed there were failures by CUMH staff to recognise and react to abnormal readings from a CTG monitor which measures foetal heartbeat and maternal contractions.
The couple’s first child, Faye, died on October 11, 2019 at Children’s Health Ireland at Crumlin where she was transferred for specialist treatment from CUMH.
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“It is most concerning that hospitals such as CUMH do not have the resources to deal with emergencies promptly as they arise. If an emergency caesarean section was performed earlier, we know that Faye would have been born intact which is devastating,” said Mr Neiland.
The couple, who subsequently had two other daughters, also claimed they felt pressured by doctors at CHI Crumlin “to agree to let Faye pass” and they criticised the lack of consultation by the hospital on any end-of-life care.
His wife gave evidence that she had an uneventful pregnancy before she was induced at CUMH on September 29, 2019 when she was 10 days over her due date.
The inquest heard Ms Neiland was given increasing amounts of oxytocin – a drug used to make contractions more regular – at regular intervals from around 11.30pm on September 30, 2019 as there was no sign of labour starting.
Her husband said they believed gels used to induce labour and oxytocin should not have been administered to his wife and the induction process should have been abandoned given the abnormal CTG tracings.
Instead, Mr Neiland said Faye should have been delivered by emergency caesarean section at an earlier stage.
He recalled a midwife hitting a panic button at around 7.15am on October 1, 2019 when they were told the baby was trapped from a contraction.
A registrar at CUMH who reviewed Ms Neiland at the time, Aoife Morris, said she directed that oxytocin should be discontinued because of concerns it was causing hyper-stimulation which could affect the foetus.
Dr Morris said she recommended that Ms Neiland should be given terbutaline, a drug used to slow contractions, which was relatively unusual in 2019 but had become more common over recent years.
Questioned by counsel for the Neiland family, Alan Keating BL, Dr Morris said she had not felt the need to escalate the patient’s care to a consultant as she was “quite happy” with her management plan.
Mr Neiland told the inquest that a midwife, Margaret Higgins, had discretely expressed dissatisfaction with a consultant obstetrician, Mudathir Abdelmaboud, about his direction at 8.34am to re-commence giving oxytocin to Ms Neiland.
Asked about this by the coroner, Ms Higgins said medical staff were aware that the baby “might not respond well to oxytocin again.”
Questioned by Dr Gallagher why he had directed the reintroduction of oxytocin for Ms Neiland when the CTG readings were similar to when Dr Morris had stopped using the drug, Dr Abdelmaboud said that while the CTS was still abnormal it had also contained “reassuring features.”
The consultant also expressed surprise that his subsequent direction for Ms Neiland to be given an immediate caesarean section was not classified as the highest level of emergency as he had anticipated.
Prof Richard Greene, Ms Neiland’s consultant obstetrician who reviewed her care at CUMH, said there had been the possibility that a foetal blood sample could have been ordered which may or may not have led to an earlier delivery of baby Faye by caesarean section.
“There is no way of knowing if the baby had been delivered much earlier, if there would have been a different outcome,” said Prof Greene.
However, he claimed there was a missed opportunity at the time to have delivered the baby instead of giving Ms Neiland more oxytocin.
Prof Greene explained the drug could result in over-contracting of the uterus which would cause distress to the baby by cutting off its supply of blood and oxygen.
He told the coroner that the initial decision to stop giving Ms Neiland oxytocin and to administer terbutaline were “appropriate responses.”
The consultant said there was subsequently an opportunity to check on the baby’s condition before recommencing oxytocin given there was a persistent slowing of its heartbeat over a long period of time.
In other evidence, Mr Neiland said deep down he felt something wasn’t right with the delivery which was confirmed when Faye’s heart rate dropped and rose rapidly after she was born shortly after 10am.
“I started to cry in fear that Faye was in major trouble but tried to hold back the tears because I could see that my poor wife was so happy with the thought that she’d meet our baby girl,” he recalled.
He added:” It all seemed so wrong to me. It was horrific. I was terrified and my wife was full of joy…to go from such a high to the nightmare that soon followed.”
Mr Neiland said it was terrible that he and Christina were brought into a recovery room which they had to share with other new parents and their new babies while Faye had been brought to a neonatal unit.
He said they were further upset that a midwife had gleefully congratulated them as she had not been briefed that there was something wrong with their baby.
Mr Neiland also complained about the amount of time they had to wait before receiving any information about Faye’s condition which he finally obtained at around 2pm.
When they eventually saw their daughter in CUMH, Mr Neiland observed that Faye had turned her head towards his wife at the sound of her voice.
The inquest heard that the couple were shocked and devastated at being informed by doctors at CHI Crumlin on October 8, 2019 that Faye was suffering from multiple organ failure and had no brain function as one registrar at the hospital had told them earlier that day that he thought their baby would pull through.
Mr Neiland said the organising of prints of Faye’s hands and toes and for a priest to come was “an awfully sad and harrowing experience.”
He described how he and his wife had been “in a zombie state” for the 10 days of Faye’s life as they were “worried about her every second of every day during that period.”
Mr Neiland also pointed out that they had no contact from CUMH after Faye had died, despite believing they would be contacted about bereavement counselling.
He said a referral for such counselling was only made when Christina was back at CUMH on a subsequent pregnancy and mentioned her emotional difficulties.
Mr Neiland said his wife, as a childcare worker, dreaded the thought of returning to work.
He pointed out the fact that one of the parents in her creche had given birth on the same day as Faye was born was one of many constant reminders of “our daughter who should be with us.”
“We will carry an everlasting sadness in our hearts. We imagine life in the way that it should have been – a life with Faye – but life reminds us every day that she is not with us,” said Mr Neiland.
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