A family whose baby son died following childbirth say they hope that “lessons have been learned” after an inquest carried out last week returned a verdict of death by medical misadventure.
Baby Darragh Mc Gorry died on 24 March 2020 at Cavan General Hospital after being delivered following a form of a ‘breech birth’ at his home in Cullies, Sherlock, in Cavan, hours earlier. His bereaved parents, Yvonne and Pauric, told an inquest that the tragedy is something they “will always live with,” as reported here by the Anglo Celt.
The Anglo Celt reports how an inquest into baby Darragh’s death was heard last week before Coroner Dr Mary Flanagan at Cavan Courthouse. Darragh’s mother, Yvonne, a first-time mum, had been receiving combined antenatal care through Our Lady of Lourdes’ Midwifery Led Unit (MLU) in Drogheda – the largest maternity unit in the North East – and through her local GP at Kingscourt Medical Practise.
Ms McGorry was almost five days past her due date when she gave birth at home. After the home birth, she was rushed to hospital to receive emergency treatment. The inquest heard how the paramedics who attended the family’s home had never dealt with a “footling breech” before. Additionally, the most senior member of personnel admitted that they did not know that vaginal delivery should not be attempted in such circumstances, as reported by the Anglo Celt.
At the inquest, it was highlighted how Ms McGorry’s care was flawed in how her antenatal information was recorded and shared. The inquest heard how “risk factors” were in existence in baby Darragh’s antenatal and postnatal care – which were “caused by medical decisions or decisions made in a medical context”.
During the inquest into the tragedy, Ms McGorry recalled seeing her husband standing outside the door of the theatre at the hospital in the wake of the home delivery.
“I could see his face. I knew by his face it wasn’t good. He came into me and sat beside me. He told me we would be ok, and to just remember we had each other, and we would be ok. I didn’t understand,” she recalled, The Anglo Celt reports.
She remembered how less than 24 hours before the tragedy, when she was four days overdue on 23 March, she had a “lovely day” with her unborn baby.
“I don’t know why but I had a feeling he was coming to meet us soon. I could not get the song lyrics, ‘If I had known you were coming, I’d have baked you a cake’ out of my head,” she told the inquest.
“So we spent the day baking butterfly cupcakes and enjoying our time together while my husband worked from the kitchen table”.
At 6.30pm that evening, she received a phone call from Our Lady of Lourdes Hospital who advised her that due to COVID restrictions, the maternity led unit was operating downstairs. In response, she told the midwife that she was feeling “a downward heavy motion” she had not experienced before, despite the fact she “wasn’t feeling pain”.
She was advised by the midwife that the maternity unit was open, and she should attend if required. However, Ms McGorry had planned and hoped to deliver her son using a birthing pool. The inquest heard that, apart from an inner ear infection, her pregnancy had gone well.
BREAKDOWN IN COMMUNICATION
The mum to be was seen by consultant in obstetrics/gynaecology, Dr Maura Milner, at 11 weeks’ gestation. At the inquest, the consultant explained how the hospital records maternity information on “cream sheets” which are given to the patient, who then brings them to their next appointment. She accepted, however, that this was not always the case.
Errors were identified in a breakdown of communication, with the inquest finding that Ms McGorry’s chart did not reference any GP notes.
Dr Milner said this situation was “unusual bit not unheard of” when asked about it by Sara Antoniotti SC, acting for the McGorry family, instructed by solicitor Rachel Liston. When asked if there were any policy of guidelines, Dr Milner responded: “Not to my knowledge”.
In her own account, GP Dr Heather McCullagh told the inquest that she saw Ms McGorry a total of three times during her pregnancy. She did not detail the findings on the cream sheets, however, but instead uploaded the details onto the Socrates software system – which automatically connects to hospitals in Dublin, but not Our Lady of Lourdes Hospital in Drogheda, Louth.
When asked if concerns were raised, Dr McCullough said that those would have been shared with the patient who would then relay them to the hospital.
“I started not to ask for [the sheets]. Some people bring them, some people don’t,” she said. Later, at an anomaly scan carried out at 20 weeks, it was identified that Ms McGorry had a low lying placenta – however, by the time of the scan at 34 weeks, the placenta was “no-longer low lying”.
Recalling the final stages of the pregnancy at the inquest, Ms McGorry said: “I remember being happy because my GP told me the baby was breech just two weeks prior”. At 37 weeks, she was informed by midwives that the baby’s head was now “two fifth engaged”.
The inquest heard how, at 39 weeks, midwife Fiona McKevitt found that the baby’s head was “[four fifth] engaged”. She was aware that baby Darragh was in a breech position at 32 weeks.
Ms McGorry, meanwhile, told the inquest that she thought [four fifth] engaged “meant the baby was moving the correct direction”
“I’ve now learnt this is not the case and in fact meant my baby was less engaged”.
GP Dr McCullagh was asked by Ms Antoniotti SC if the pathways of communication between hospitals and GPs for combined care would be better if standardised.
She replied that “communication is always good”.
When her due date came at 40 weeks, Ms McGorry visited her GP. Because her “usual” GP Dr Heather McCullagh was unavailable, she was seen by Dr Deborah Ryan. The inquest heard how the appointment was “brief” and Ms McGorry recalled Dr Ryan placing the ultrasound doppler “high on my stomach, near my belly button”/
She said: “This was unusual as normally the GPs and midwives were listening lower down”.
While she mentioned this to her husband, Pauric, she says she “did not think any more about it”. Dr Ryan denied saying a fortnight after baby Darragh’s passing that she wasn’t “100 percent confident” in her abilities to say if the infant was cephalic, a position in the womb which would typically allow the easiest delivery.
“No examination is 100 percent accurate,” she said. “Not that I was not used to doing examinations”. The doctor also stated that the “notes weren’t provided” to her for Ms McGorry that day.
Contractions began at 8.30pm on 23 March, just after Ms McGorry was coming off a zoom call with friends. Her husband Pauric encouraged her to stay calm.
“We got the hypnobirthing strategies out,” Ms McGorry told the inquest. “We also got the Tens machine ready and my husband ran me a bath. I began timing my contractions. They were coming every 20 minutes initially”.
By the time it was 11:30pm, her contractions were “stronger, more frequent” – every ten minutes. When her mucus plug released, she recalled how she “had a little panic, but remained calm, called my husband, and he said it was time to call the hospital”.
Ms McGorry put the midwife on speaker phone, and to her disappointment, she was informed by midwife Orla Keegan that she was “not in labour” and that this was her “body’s way of getting ready for birth” as a first-time mother. Ms McGorry told the inquest that while she was concerned about living an hour away from the maternity hospital, the midwife reassured her she was “not in labour and these things take time”.
Giving evidence, Ms Keegan denied that she told Ms McGorry not to attend. She claimed she would have suggested that Ms McGorry was “not in established labour”. However, the midwife conceded amending a note referring to this, which was countersigned by her colleague Rhona Byrne.
“The decision to do this was my own,” she said, but insisted it was done after she consulted with senior medical staff the day after baby Darragh’s death. “I felt it was important to note,” she said.
Meanwhile, midwife Byrne said she overheard the phone call and the advice which was given to the first time mum, adding that this was “standard”. She said she did not remember seeing “any GP notes” in Ms McGorry’s file.
Come 2:45am, the pain was very strong and Ms McGorry took another bath. Following that, she sat on the toilet in a back to front position and began timing her contractions.
“Some were lasting over a minute, others weren’t,” she recalled. Ms McGorry said she remained in that position for a few hours until she reached the point where she could “not go on” any longer. Assisted by her husband, she said she remembered seeing drops of blood in the bowl.
At 7:50am, she called the MLU again – almost 12 hours after the contractions started. Midwife Keegan answered the phone, and Ms McGorry recalled “giving her examples of frequency and duration” of the contractions/
“The intensity had massively increased. I could no longer stand through them and needed to squat,” she said – adding that she told the midwife about the drops of blood.
However, she said that “to our horror and disappointment, again she told us that we were not in active labour” and “if I wasn’t coping, I could come in for a check but I’d be sent straight back home again”. The couple decided to go to the hospital.
She says that in a state of utter exhaustion, she thought that “maybe the midwife was right, maybe I wasn’t in labour. I didn’t know what to do”. However, at 8:55am, her waters broke and she rang MLU from the bathroom.
On this occasion, she was told to come to the hospital by midwife Chantalle Murdock. But while she was on the toilet after getting a shower just before planning to leave, she experienced what she described as “an almighty contraction, much different to the others.”
She said the “push contraction” felt like “involuntary impulses” and had three of these contractions in quick succession.
“I was in horrific pain, unable to move,” she recalled.
She told the inquest that she could feel something between her legs, and the couple called the mLU for a fourth time at 9:02am. A different midwife, Fiona Maloney, answered the phone.
The inquest heard how a “frantic” Ms McGorry – who was at home with “no medical help” — told the midwife what had happened in the 12 hours that had unfolded.
“OUR LIVES CHANGED FOREVER”
At this point, the midwife’s “voice changed” and Ms McGorry was told to hang up the phone and ring an ambulance straight away. The inquest heard in harrowing terms how, after being told to do so by the ambulance dispatcher, Mr McGorry checked between his wife’s legs.
“Then he said the words, ‘It’s the baby’s foot’ – and our lives changed forever. At this point, I knew we were in danger. I knew my baby was in danger and my life too”.
The closest ambulance was a full 35-40 minutes away, and in the meantime, Mr McGorry tried to do everything he could to prepare for the babies’ possible arrival.
Reflecting, she said: “If only we’d have been so lucky to have our little baby arrive”.
At 9:37am, the first ambulance arrived at the home. Ms McGorry said that at this point, she thought “we were ok”.
“It hadn’t crossed my mind that the baby was struggling. My husband had been watching the baby’s toes and foot wriggle. This provided me with reassurances”.
She was told by paramedic Sharon Dalton that she would “likely” be transferred to the hospital. She recalled: “I was crying out in agony by this time, so scared and couldn’t figure out how I’d survive the journey.”
She remembers how, despite the trauma, she “trusted” the ambulance staff. An advanced paramedic, Robert Murphy, arrived shortly afterwards, followed by two more paramedics close to 10am.
The most senior medical personnel present at the delivery was Dr Murphy, who was on duty in Monaghan when he received a call just after 9:00 am. He arrived at the home almost 30 minutes later. Recalling this, he told the inquest: “I couldn’t have driven any faster” with the situation labelled as “delta, non cardiac” by the response staff, meaning it was second highest in terms of urgency.
Paramedic Mr Murphy told the inquest how he became aware it was a footling breech delivery, and said that he made the clinical decision to deliver in situ. He said he did this for two reasons – firstly, the difficulty in delivery in a moving ambulance, and secondly, because of the time which had already passed.
While he did not carry out a vaginal exam, he could see a “leg presenting”. The inquest heard how he had never dealt with this type of breech before, and that none of the paramedic staff present had. He was unaware this was contraindication to vaginal delivery.
Asked if he thought he should have sought medical assistance relating to the algorithm used for dealing with emergency scenarios, he said that there was “no local policy on that”. He admitted he had not had training to deal with such a situation, adding that it had not been communicated to him that the emergency operator had said “don’t push”.
Mr Murphy then called Our Lady Of Lourdes Hospital’s maternity unit and spoke to midwife Maloney on the phone.
He insisted he had his best intentions at heart, adding: “At the time I was doing what I thought was best”. Midwife Maloney told the inquest that she would not have told the paramedic to attempt to deliver if she had been told it was a footling breech. She would have advised them to bring Ms McGorry to the hospital immediately.
She said that since the incident occurred, expectant mothers are told to attend the hospital on their due date. The inquest heard heartbreaking details about how baby Darragh’s leg was stuck, after which his shoulders and head also got stuck.
Mr Murphy said that the umbilical cord was “not pulsating at any point” during his time at the McGorry home. Baby Darragh was born at approximately 10:35 am – a full hour and a half after delivery started.
“I CRIED OUT FOR MY BABY’
Ms McGorry said she realised her little boy was not making any noise.
“They didn’t put him on my chest,” she said. “The room was silent. I cried out for my baby, asking “was he ok”.
She said the response was that baby Darragh “needs a little bit of help”. The distraight mother heard the medics counting as they undertook CPR. She said she was too afraid to look and see her baby “in this way”.
She said at this point, she and her husband started to pray.
She told the inquest that she then heard a paramedic say “I think we have something” which provided a glimpse of hope.
“We looked up. They told us Darragh was very sick and needed to go to the hospital immediately.”
She said that during the 35-40 minutes it took to get to the hospital, the “absolute shock and disbelief of what had just happened” began to set in.
“I thought about Darragh, what we might be faced with. Mt brain didn’t allow me to think he was dead,” she said.
Considering what the situation might be like had her baby been starved of oxygen to the brain, Ms McGorry said:
“I told myself it would be ok. We would manage, Pauric and I would be able to look after him and give him what he needed”.
However, when Ms McGorry and her husband arrived at the hospital, staff would not tell them about Darragh, the inquest heard.
“They kept saying the consultant would talk to me,” she said.
Consultant Dr Ann Leahy had to deliver the news that baby Darragh had died.
Ms McGorry said she looked to her husband, “desperate for him to tell me it wasn’t true”.
The baby’s time of death was recorded as 11:34am. When asked if she wanted her baby boy brought to her, she recalled: “I was so scared. I didn’t know what had happened, was he hurt? Had he visible injuries.” At this stage, she didn’t know the cause of death and “nothing had registered”.
‘IT WAS INSTANT…MY BEAUTIFUL BABY BOY’
Baby Darragh was carried to his mum in a blue blanket by Dr Leahy.
“I looked away, afraid of what I might see,” she said. “My husband took him and then something inside me told me to look – I think it was my mother’s instinct. I looked at him and it was instant. My beautiful baby boy.”
The couple thanked staff at Cavan hospital for their care, which they described as “excellent”.
She said it was nice to know that her little boy “had touched the hearts of many” after many of those who worked to try and save Darragh expressed their sympathy.
That night, the McGorrys spent the night together for the first and last time as a family of three. They had to say goodbye to Darragh the next morning and his body was brought for a post-mortem.
This found that any of the factors relating to delivery by footling breech could have contributed to the death.
Acute cord compression, along with entrapment, were listed as possibilities by consultant perinatal histopathologist, Dr Noel McEntagart.
His findings were that the little boy died of “acute hypoxic effects”, and at the request of the family, also recorded “early neonatal death post vaginal breech delivery”.
Ms McGorry detailed in devastating terms how “we left the hospital without my baby”.
“We left the hospital with a box instead of our baby. That walk was the hardest, most painful thing I’ve ever had to do. I genuinely don’t know how I managed”.
Baby Darragh was returned to his parents, presented in his coffin, the following Monday,
“I knew he was okay and safe, that’s all I needed,” Ms McGorry said. He was “still so beautiful,” she said. Before he was laid to rest, his parents gave their son a letter.
“We gave him his baby elephant from his nursery, and his daddy has he matching one beside our bed.”
Baby Darragh was also given a holy necklace and a guardian angel gift from his grandparents, and a toy rabbit and letter from other family members.
“We made sure he had his hat on and his blanket wrapped tight. We said our goodbyes and carried him out of the hospital – not in his car seat like we’d planned, but in a tiny white box,” Ms McGorry told the inquest.
The inquest reached the verdict that acts of failure to transfer, to diagnose the problem, and to admit the new mother to the hospital, when she was clearly in labour, reflected a verdict of medical misadventure, the McGorry’s legal representation contented.
The hospital and the HSE – represented by barrister and former doctor Simon Mills SC – disputed this assertion, instead offering a ‘narrative’ verdict. Mr Mills argued that medical misadventure was “problematic”. This position was supported by the solicitor who acted for the GPs involved in the case.
However, following eight hours of evidence and multiple witness accounts, Dr Flanagan came to the conclusion that the case was “best served” by a verdict of ‘medical misadventure’.
As detailed by the Anglo Celt, Darragh’s father, Mr McGorry “broke down” and was comforted by his wife. Dr Flangan said that the outcome was not about placing “blame” on anyone, but that the baby’s death was the result of “an unintended act”.
Baby Darragh’s death was recorded as “early neonatal death post vaginal breech delivery”. Following the inquest, baby Darragh’s parents Yvonne and Pauric say they hope “lessons have been learned,” as reported by the Anglo Celt.