Irish preventable deaths campaign organisation, Safer Births Ireland, has reiterated calls for an investigative inquiry into such deaths, after an inquest heard that a baby girl suffered fatal brain damage during birth after delivery was delayed at the National Maternity Hospital.
The group believes a National Independent Maternity Commissioned Inquiry is needed in Ireland, pointing to “an alarming increase” in the number of avoidable baby deaths and maternal deaths. They also say that numerous children have suffered unnecessary lifelong injuries due to negligence or malpractice during childbirth, and that such incidents are not isolated but indicative of systemic issues within Irish maternity services.
On Tuesday, a verdict of medical misadventure was recorded in the death of six-day-old baby Molly Taylor Smith, who died from hypoxic ischemic encephalopathy – a lack of oxygen or blood to the brain – on 19th May 2020 at Holles Street in Dublin.
The National Maternity Hospital admitted that failings in its care led to the baby girl suffering fatal brain damage during labour. Baby Molly died six days after being delivered by emergency c-section, with the inquest hearing that delivery had been delayed in order to allow her mother to take a Covid test.
The inquest at Dublin District Coroner’s Court heard that the delivery had been delayed to get the results of the Covid test on Molly’s mother, Joanne Taylor Smith.
Hospital registrar, Dr Adriana Olaru, gave evidence that she decided that the baby should be delivered by C-section at 11pm on May 12, 2020 because the labour was slow and Joanne had a fever. Dr Olaru said that readings from the CTG, which measures the baby’s foetal heartbeat, were “satisfactory” at the time, and said that the decision to wait roughly 50 minutes for the results of the Covid test – to allow the baby’s father into theatre – was “reasonable” given the circumstances.
However, the CTG readings once the results of the Covid test became available, almost an hour later at 11:55pm, showed “pathological changes,” which meant an emergency c-section was performed to deliver the baby. Dr Olaru testified that baby Molly was “in poor condition” at the point of delivery.
When questioned by coroner Clare Keane, the doctor said that she was satisfied with the CTG readings at 11pm, and that she “did not feel Molly was in any particular danger.”
She said, however, that she would have been concerned had there been changes in the CTG readings, and if that was the case, delivery would have had to been expedited and the medical team would not have waited for the Covid test.
However, Dr Olaru said changes in the CTG readings had not been brought to her attention. She said that she believed a change in the CTG was “noted” but that had not been communicated to medical staff.
Consultant neonatologist Anna Curley told this week’s inquest that Molly was not breathing at birth, and it took two and a half minutes to restore the baby girl’s heartbeat. Dr Curley said that her condition rapidly improved, but that a decision was made to provide cooling treatment.
It was an MRI scan performed when the baby girl was five days old that confirmed she had suffered extensive brain damage, consultant obstetrician and gynaecologist, Stephen Carroll, told the inquest.
A decision was made to give baby Molly palliative care when she became “critically” unwell, the inquest heard.
Mother Joanne Taylor Smith told the inquest that her child would be here today had she been born a lot sooner.
She recalled how she had been admitted to hospital on 11th May 2020, after what had been an uneventful pregnancy. By this stage, she was six days overdue with her first child.
Ms Taylor Smith fought back tears as she recalled being “super excited” to meet her baby, and that she and her husband, Keith, had chosen to keep the gender of their child a surprise.
She said that her “strong, brave little girl” was born at 12:17am on 14th May, 2020, and remembered being “so happy but confused” after Molly was born, when she was advised by medical staff that the baby would need to be brought to a neonatal intensive care unit “for a little bit of help”.
She recounted how the couple had waited over the course of the following days to see whether the baby would recover from the “horrific” brain injury.
“If she was born a lot sooner, she would be here,” Ms Taylor Smith told the inquest. She said the couple now visit their baby in her “forever bed,” adding: “That is how we look after her now.”
Ms Taylor Smith also said that she would have loved her baby girl to have been able to meet her younger sister, but also expressed a sense of pride that Molly had been able to help save another life as the couple had donated her heart valves, which were transplanted to another newborn baby.
A verdict of death by medical misadventure was returned, with the coroner expressing condolences to the couple.
Safer Births Ireland told Gript that the story was heartbreaking, with the campaign organisation saying they were saddened to read about another “totally avoidable baby death that brings a lifetime of grief and heartbreak for her parents and extended family.”
“There will now be a lifetime of family events where tragically Molly now will be missing, all due to the mismanagement of Joanne’s care. This is simply just not good enough. When will our Taoiseach Simon Harris commit to completing the investigative inquiry that we sought from him on April 23rd?”
The group, which is made up of bereaved parents and families, said it was disgraceful that CTG monitoring was not acted upon.
“The question is why so many cases we hear of normal CTGs and the baby being born in a catastrophic hypoxic state,” they added. “The CTG should mirror the foetal distress so why are so many not doing that?”
Safer Births Ireland have reiterated calls for a national independent maternity-commissioned inquiry to take place in Ireland. The group has previously hit out at the investigative process which they believe is unfair, and lacks transparency.