An inquest in Cork was told that the safety device on a needle used to take a blood sample from a baby's scalp failed and the needle cut a vein, resulting in the baby's death a few hours later.
Dr Fani Langdana, a gynaecologist, said yesterday: "It was absolutely shocking. This should not have happened." The coroner stated that the fact that the blood testing machine was not working seemed to be a material factor in the baby's death.
Dr Langdana was giving evidence at a resumed inquest in Cork into the death of the baby, Denis McMahon, whose parents, Bernadette and Tadhg, are from Mounrenabbey, near Mallow.
A solicitor for the family, Mr Carey, reading a statement from the family, said they bore no ill will, no grudge or ill feeling against the hospital or any members of staff over what had occurred.
They merely wanted to have their second child, which Mrs McMahon is expected to have by caesarean section later today in St Finbarr's hospital, and get on with their lives.
However, he added, they were reserving their legal position for a future date. The baby was critically ill when he was born by caesarean section in St Finbarr's hospital on August 27th, 1996. He died a few hours after birth, despite strenuous efforts to resuscitate him.
Dr Langdana said Mrs McMahon went into labour at 8.30 a.m. and an epidural was given at 11 a.m. There was no evidence of foetal distress at this stage, but later during labour he detected intermittent abnormalities in the baby's heart trace.
"This is an indication that a blood sample should be taken. This would show if the baby was deprived of oxygen. This procedure was uneventful. I got a blood sample and sent it for analysis, but unfortunately the machine was malfunctioning and we could not get a reading."
There was only one machine in the hospital, he said. In the meantime, the baby's heart rate went back to normal.
"I reviewed the situation with Dr Maurice Minogue by telephone and we were happy at that stage to allow labour to proceed normally. However, further abnormalities were detected in the baby's heart rate.
"I was told the machine was functioning again and I decided to take another foetal blood sample.
"It was a very mild abnormality but we wanted to make sure the baby was not distressed. This blood sample was taken and again the procedure was uneventful." Dr Langdana said that while blood samples were being taken, the doctor could see clearly everything he was doing. "It is not done blindly," he said. After the second sample was taken, Dr Langdana noticed blood oozing from the incision and he applied a gauze dressing. Once again he was told the blood testing machine was malfunctioning.
Dr Langdana said that at this stage the baby's heart rate showed a marked abnormality. He rang Dr Minogue and they decided to perform an emergency section.
"The baby was in very poor condition when I delivered him. He was very pale. I handed him over immediately to the paediatric team." Dr Langdana said the basic cause of the bleeding was a blade penetrating a vein in the baby's scalp.
"The safety stop should have prevented the blade going in too far. It was absolutely shocking. It should not have happened."
Replying to Mr Carey, the solicitor for the McMahon family, Dr Langdana said the medical team had reviewed medical literature extensively and this situation had never happened before.
Dr Maurice Minogue, senior gynaecologist, said the blood sampling was a common test. "It could not be more surprising that this happened. I contacted the distributors and manufacturers of this blade in the UK and there is absolutely no record of a fatal perforation of this kind."
Dr Minogue added that if the blood test machine had been working and they got a normal reading, a second sample might have been taken later.
"It would have been quite in order to repeat the test. These machines are temperamental."
Prof Peter Kearney, consultant paediatrician, said that when the baby came under his care soon after birth he was in a critical condition. "He had a one in 10 chance of survival," he said.
Dr Catherine Keohane, who performed the post-mortem examination on the baby said he had extensive swelling on one side of his head as a result of bleeding from a wound on the right of his scalp. Death was due to shock from bleeding. The baby had low clotting factors in his blood, which may have contributed to his death, but the main factor was blood loss.
The Cork City coroner, Dr Cornelius Riordan, said: "The procedures adopted in the circumstances of the birth were reasonably standard.
"The taking of a blood sample would appear to be standard practice although obtaining it is a very delicate operation. I don't know how long the blood test machine was malfunctioning, but it seems to be a material factor in the death of the baby.
"The emergency section would not have been so long delayed if the machine was working. This poor baby lost its life very tragically," said the coroner, who had previously adjourned the inquest, calling for a fuller explanation from the hospital of the circumstances.