Verdict of medical misadventure returned into death of baby at Kilkenny hospital

A verdict of medical misadventure has been returned at an inquest into the death of a baby girl who died within hours of an attempt being made to deliver her by vacuum suction.

Kilkenny Coroners Court heard Baby Livia Angel Urkova-Marini, who was the only daughter of Ludmila Urkova and Aldo Marini, from Carlow town, was born at 12.04pm in St Luke's Hospital, Kilkenny on May 18, 2014, and died at 7pm that evening.

Her mother had a condition called vasa previa, which involves the baby’s head pressing down on the womb membrane and on the blood vessels running between the baby and the placenta, the inquest heard. It is a condition which affects just one in every 6,000 pregnancies and can lead to fatal blood loss in the baby.

Former Master of the National Maternity Hospital, Dr Peter Boylan, told an earlier hearing that when the blood vessels are lying near the neck of the womb, there is a risk of a tear once labour starts and the womb neck opens. In this event, foetal blood is lost. That is what happened in the case of Ms Urkova.

Dr Boylan, who reviewed the records, believed an attempt at vacuum delivery of this baby by the registrar on call “should not have been done”. This was due to the mother’s cervix not being fully dilated.

Under questioning from Paul McGinn SC, for the hospital, Dr Boylan agreed that vasa previa was “undiagnosed” prior to delivery. “It’s an extremely difficult diagnosis to make,” he said.

The coroner, Tim Kiely, directed the jury to return a verdict of medical misadventure, noting that that the death of the baby was as a result of attempted vacuum delivery "which was a medical error or medical mishap".

The application of that vacuum cup had the “unintended outcome of causing a bleed which led to the death of the child”, Mr Kiely said.

The inquest was told by midwives that the protocol was that they would initially call the registrar on call to review a public patient. “If it’s a private patient you would contact the consultant,” midwife Emma Murphy said in evidence last year.

The registrar, Dr Ali Gerwash, arrived at 11.10am and attempted two “kiwi vacuum” deliveries, using a kiwi vacuum cup, but was unsuccessful.

The consultant, Dr Yuddandi Nagavini, arrived at 11.55am and found a “faint” foetal heartbeat. She performed an emergency caesarian section and delivered baby Livia at 12.04pm, but the baby was in poor condition and died at 7pm.

The 11 member jury, when returning their verdict, made a number of recommendations. These included that “good communication practices” between medical professionals in emergencies be implemented and also that patients, whether public or private, have access to appropriate and timely medical care. They recommended too that scans be carried out to ascertain the risks of vesa previa and that the HSE should provide training in cases of vasa previa.

Solicitor for the baby’s parents Raymond Bradley told the inquest the family hopes St Luke’s Hospital and the HSE takes away each of the recommendations and acts on them.

He also said the case “highlighted a dichotomy between public and private patients” which was wrong.

A verdict that death was as a result of birth asphyxia and haemorrhagic shock, secondary to vesa previa was returned.