A senior consultant admitted that St Luke’s General Hospital in Kilkenny had failed in the care of a baby who died five days after an “acute event” at birth, as well as in the treatment of her mother, who was 11 days old. delay. .
Baby Laurence Somers died at Coombe Hospital in Dublin on January 28, 2018 after being transferred from St Luke’s Hospital following complications during her delivery through an emergency cesarean section.
Dr Trevor Hayes, clinical director of Obstetrics and Gynecology at St Luke’s, told Dublin District Coroner’s Court he had accepted that Laurence was a normal baby delivered in poor condition.
Appearing before an inquest into the death of baby Laurence, Dr Hayes offered a heartfelt apology on behalf of the hospital to the boy’s mother, Gráinne Somers and his family.
Ms Somers, a mother of two other children who lives in Kilkenny, testified on Monday when she criticized the lack of information provided by St Luke’s staff on the severity of their son’s illness or that he had to be resuscitated at birth.
The consultant said on the second day of the investigation that he would not list the hospital’s failings because they “would be obvious”.
However, he expressed hope that his presence in court would give the family some degree of closure.
Dr Hayes admitted that an ultrasound should have been performed, as required by St Luke’s policy for pregnant women who are ten days late, on Ms Somers on January 22, 2018 – the day before Laurence was born – when ‘she went to the obstetric assessment at the hospital. unity.
– The ultrasound should have been done, there is no doubt. The protocol is there for a reason – to be followed, ”Dr Hayes said. The consultant said it was difficult to say exactly why baby Laurence died, but he noted that there was evidence the boy inhaled meconium (mucus and bile found in newborns) in his lungs which he described as having a “thick pea soup”.
While it’s very easy to speculate in hindsight, Dr Hayes said the result might have been different if an ultrasound had been performed on Ms Somers on January 22, 2018.
Asked by Somers family lawyer Sara Antoniotti BL on whether the boy could have survived had Ms Somers been induced by that date, Dr Hayes said he believed he would have “had a good blow that he did not have “.
Dr Hayes also said he did not believe Ms Somers should have been placed in the care of a senior household officer for her pregnancy as he was “not sure she should have been placed in a group low risk “.
The inquest had learned that Ms Somers and her husband, Laurence, both had certain antibodies which increased the risk of anemia in their babies.
However, a scheduled check of her antibody levels was not done in the month before her son was born.
Dr Hayes admitted Ms Somers’ care should have had “a consultant’s fingerprints”.
He also conceded that every patient should see a consultant at least once during her pregnancy, although Ms Somers had admitted this had not happened in her case.
The inquest found that several changes had been made to maternity care at St Luke’s following the tragic death of baby Laurence. A dedicated consultant has now been appointed responsible for the hospital’s obstetric assessment unit instead of rotating staff to oversee the unit.
Patients can also only leave the unit after completing a checklist indicating that an appropriate, patient-approved plan is in place.
Dr Hayes said patients were also now made easier whenever they wanted to be seen by a consultant, while all clinics ended with a “safety caucus” by staff to address concerns about the care of any. patient.
The medical teams were also subjected to “regular skills and exercises”, he added.
Ms Antoniotti said her clients appreciate the openness and honesty shown by the consultant and welcome the changes to St Luke’s.
However, she claimed that testimony from two other doctors on Tuesday who saw Ms Somers the day before her son’s birth showed it was not clear who was responsible for his care, while the use of a ultrasound seemed to have been optional for women. on the term.
Coroner Dr Crona Gallagher delivered a medical mishap verdict which she said was based on “critical evidence” from an ultrasound that did not take place.
Had an ultrasound been performed when Ms Somers was ten days late, Dr Gallagher said her results could have caused her to give birth earlier.
However, she stressed that her conclusion should not be taken as a comment on the quality of care provided to Ms Somers or on accountability.
The coroner welcomed the fact that many of the recommendations she had considered making appeared to have already been put in place by St Luke’s following the death of baby Laurence.
Dr Gallagher made the additional recommendation that all physicians and midwives be required to undergo training in local protocols and procedures before starting any new roles in hospitals.
Speaking to reporters after the hearing, Ms Somers said the verdict had been a long time coming but they had finally secured closure.
Ms Somers said she and her legal team had fought tirelessly for answers over the death of her “beautiful and perfect baby boy”.
“We now know that hospital guidelines were not followed,” Ms Somers said.
She added: “We hope that healthcare providers take into account the importance of listening to pregnant women and their concerns, and that the recommendations made by the coroner will be implemented by St Luke’s Hospital so that ‘no other parent and family has to endure the pain we will live with for the rest of our lives.