Women giving birth in maternity units as well as staff should have access at all times to the expertise provided by consultant obstetricians, a coroner has recommended.
Regular training should be provided for obstetric staff on how back pain alone can indicate the start of labour, Laois coroner Eugene O’Connor has also recommended.
Mr O'Connor was returning a verdict of medical misadventure at an inquest into the death of a baby boy at Portlaoise hospital in October 2018.
Luke Duffy died in the hospital on October 29th, a bank holiday Monday, after suffering acute hypoxia, the coroner found.
For the three preceding days, his mother Lisa had begged staff to induce his birth but they refused because, she said, they failed to recognise her extreme back pain as a sign her labour had commenced.
Ms Duffy was not examined by a consultant for six days before Luke’s death. The inquest heard evidence the maternity unit was very busy over the bank holiday weekend and all available slots for inducing the baby were booked until 6pm on October 29th, the day he died.
Baby Luke was delivered stillborn a day later, following a “harrowing and protracted” labour, she said.
Ms Duffy said healthy babies are losing their lives because medical staff “think they know best”.
“It’s a pandemic in its own right,” she said, adding that staff need to recognise that “women know their bodies best” and to act on their concerns.
Michael Knowles, general manager of the Midland Regional Hospital Portlaoise, expressed "sincere apologies" for failings in the care given to baby Luke and said it would do "everything possible" to ensure they did not happen again.
Ms Duffy, from Mountrath, said she had experienced back pain only, and not abdominal pain, but she wasn’t examined by staff as “they didn’t believe it was genuine”.
Consultant obstetrician Dr Miriam Doyle, who was not on duty on the weekend Ms Duffy was admitted, agreed back pain has a "recognised association" with labour. Some women experience only back pain during labour and for others it starts in the back and moves to the front, she said.
Ms Duffy’s pregnancy was considered high-risk and induction of her baby was suggested during a visit to the hospital in mid-October 2018. On October 26th she presented with contractions.
She said her understanding, based on a conversation with staff two days earlier, was that she was going into hospital that day to be induced.
Ms Duffy said she asked registrar Dr Anthony Breen to begin the induction process but he said they were sticking to the original plan to induce her on October 29th.
On Saturday October 27th, she again asked Dr Breen to begin induction but he suggested she might be more comfortable at home.
On the Sunday, she said she again begged for induction but Dr Breen refused.
She started to worry about her ability to push out the baby as she was so tired. “No internal examination was carried out as each midwife claimed I would only get an infection and since I did not have any abdominal pains my baby was not ready to come out.”
On Monday October 29th, she said she felt fetal movements after breakfast but shortly afterwards a nurse was unable to detect the baby’s heartbeat. Fetal death was diagnosed after 9am.
She said Dr Doyle came to her later in the day and seemed surprised that she had not been examined since the Friday.
Ms Duffy said she was initially advised to go home and “process the news” despite being in labour. But she was kept in due to high blood pressure and she eventually delivered her stillborn son Luke the following day, October 30th, at 39 weeks and two days gestation. She described the labour as “a living nightmare”.
Dr Doyle agreed with Sara Antoniotti BL, with Liston Flavin solicitors, that Luke would have been born alive if he had been induced earlier.
She said the problem was that it wasn’t possible to book a slot for induction earlier than Monday October 29th.
She said the level of activity in the unit in the preceding days - a bank holiday weekend - was such that all available slots were full.
A consultant was on-call in the unit at all times and it was “unlikely” he was not in the hospital at the time, she said.
The inquest heard Dr Breen was unavailable to give evidence to the inquest on Monday, a situation the coroner described as “unsatisfactory”.
Consultant perinatal pathologist Dr Peter Kelehan said baby Luke was a normally formed, big infant on examination, with no evidence of congenital abnormality.
Portlaoise hospital has been the subject of several reports into baby deaths at its maternity unit over the past decade. From 2012, it emerged at least five babies had died in the hospital due to a lack of oxygen after staff failed to recognise or act on signs of foetal distress.
Monday’s inquest took place 10 years to the day from the death in the hospital of newborn Mark Molloy, whose parents Roisin and Mark have since campaigned for improved standards in maternity care.
Speaking after the inquest, Ms Duffy and her husband Mel described their son’s death as “something that should never have happened” and said the tragic events that took place over the 2018 October bank holiday weekend “continue to cast a shadow over our lives”.
“We believe that learnings must come from his sad and needless loss, that expectant mothers must be listened to, for the safety of both the mother and the baby. Individual staff accountability for all must be the watchword from this day forward.”
