A baby boy who was delivered at the National Maternity Hospital on Dublin’s Holles Street following an attempted home birth died five days later, an inquest has heard.
Ben Kane, son of Niamh Gray and James Kane from Lusk, Co Dublin died at the hospital on February 12th, 2022.
Dublin District Coroner’s Court heard on Thursday that Ms Gray was transferred to Holles Street during her labour when midwives discovered swelling on her cervix and reasoned that birth would not be possible at the home.
The court heard that midwives who were caring for Ms Gray at her home, Niamh Bates and Angela Cotter, did not have any concerns about the wellbeing of the foetus when the transfer occurred.
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The cervical swelling was discovered during a vaginal examination carried out at Ms Gray’s home at about 1.30am, Ms Bates told the court. She described the discovery as “grossly abnormal” and moved to transfer Ms Gray to Holles Street hospital.
It was the second such examination Ms Bates carried out – the midwives did not detect swelling in the first examination carried out at 12.50am, the court heard. Ms Bates told the court she was prompted to carry out the examinations because Ms Gray’s labour was not progressing.
Ms Bates told the court that she did not carry out a vaginal examination in her initial assessment of Ms Gray, when she arrived at her home earlier that evening, after 10pm.
Sara Antoniotti SC, for the deceased family, put it to Ms Bates that HSE homebirth guidelines state that, on arrival at a mother’s house, the midwife should determine the onset of labour by carrying out assessments – including, if a mother is contracting, a vaginal examination.
Ms Bates said she made a clinical decision to defer the vaginal examination on her arrival at the house because she believed the birth was imminent and she had some concerns about causing infection. “I deemed it not appropriate at that time,” she said.
Bríd Shannon, a clinical midwife manager, told the inquest that she was told by Ms Cotter that Ms Gray was being transferred to Holles Street because her labour was not progressing, but was not made aware of the swelling in her cervix.
In Ms Cotter’s account of the phone call, she said that she informed the hospital of the swelling, but said that she did not describe it as an obstruction.
Ms Shannon told Ms Antoniotti that in the event of an obstructed labour, she would, in her experience, inform doctors of the situation.
Ms Shannon said that the swelling of the cervix indicated that the baby was “stuck in this position for a period of time”, stating that it was a “common finding” for a labour going on for an extended period of time, but not progressing.
Ms Gray told the court that following her arrival in the hospital, after 2.45am, she repeatedly asked for a caesarean section. Ms Shannon noted that the mother was “extremely distressed” on arrival at the hospital.
Midwives had difficulty in obtaining heartrate readings using an cardiotocography (CTG) machine, the court heard.
About 20 minutes after Ms Gray arrived in a hospital delivery room, two registrars were called to assess her. A decision was then made to expedite the delivery, and one doctor manually rotated the baby.
Following this shift in position, there was “significant” descent of the baby in the birth canal, and Ben was born at 3.50am, Ms Shannon said.
He was unresponsive at birth, the court heard, and while there was a heartbeat detected, there was no respiratory effort.
At 4.20am, Ms Gray told the court, a neonatal consultant advised her that her baby was very sick, and that doctors had concerns about his brain activity.
When she asked the consultant if Ben would die, the consultant said that she did not know, but that “they would do everything they could”.
It was later explained to Ben’s parents that he was on life support and they were advised to “prepare for the worst, that his injury was severe”, Ms Gray said.
A subsequent MRI scan showed that Ben would not recover from injury sustained intrapartum, and palliative care plans were commenced, Ms Gray told the court.
“Ben spent the night on our chests and he passed away at 6.44am on February 12th, 2022 in my arms,” Ms Gray said.
Witnesses who gave evidence on Thursday expressed sympathies to Ben’s parents. “I’m so sorry that this happened to you, and I’m really sorry if you feel that I Iet you down in any way,” Ms Bates said tearfully from the witness box.
At the close of evidence of Thursday, Ms Antoniotti submitted to the court that it was “unfair” on the deceased family that an electronic CTG record – what she described as “vital” evidence – was received by the family’s solicitor, Amy Langan of Rachael Liston LLP, one day before the inquest opened, “at the 11th hour”.
Simon Mills SC, for the NMH and HSE, said it was an “oversight” that the CTG record had not be sent to the deceased family’s legal team before Wednesday. Coroner Dr Clare Keane clarified her office has received the record on Wednesday.
The inquest will continue later this month.
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