The National Maternity Hospital has apologised to the parents of a baby who died four years ago and said it failed to “appreciate” changes in a foetal heart rate tracing.
Molly Taylor Smith was born at the hospital on May 13th, 2020, and died six days later, after suffering hypoxic ischemic encephalopathy, a type of brain injury that occurs when it experiences a decrease in oxygen or blood flow.
An inquest into her death at Dublin District Coroner’s Court on Tuesday delivered a verdict of medical misadventure. It heard that Molly’s mother, Joanne Taylor Smith, was admitted to Holles Street Hospital in Dublin on May 11th, then six days overdue.
The inquest was told that Ms Taylor Smith had a “relatively uneventful antenatal course” until induction had commenced on May 11th for evolving pre-eclampsia.
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Dr Adriana Olaru, a registrar doctor at the time, said a CTG [cardiotography] reading of the foetal heart rate was noted as suspicious at 6.40pm on May 12th but by 8pm it was viewed as satisfactory.
She said at 10pm, Ms Taylor Smith had a spike in temperature at 38 degrees and as per protocol at the time, was tested for Covid-19.
Dr Olaru was informed at 11pm that the CTG had again been reviewed and found to be satisfactory and the decision was taken to deliver by c-section. She said it was decided to wait for the Covid-19 result, which would be ready in 50 minutes and this was “acceptable as long as the CTG remained satisfactory”.
Dr Olaru added that Ms Taylor-Smith had expressed her wish to have her husband Keith present at the delivery, if possible.
Dr Olaru said at 11.55pm, the Covid test had come back as negative but the CTG had “pathological changes”. Dr Oraru said she had left the ward at 11pm but it was not communicated with her of the changes to the CTG from “satisfactory to a pathological in the meantime”.
She told the inquest she could not comment as to why changes in the CTG had not communicated to her or the medical staff.
Ms Taylor Smith was sent for delivery and baby Molly was born at 00.17am on May 13th following an emergency C-section and transferred to neonatal ICU, but died on May 19th.
Ms Taylor Smith spoke of how she and her husband were “super excited” to meet their baby and didn’t know the gender in advance.
She said she was “so happy” to discover they had a baby girl while describing the following days as “difficult”.
“We visit Molly at her forever bed. This is how we look after her now,” she said. “She was a perfectly healthy baby and we miss her every day. We think of what she would be like and how her sister and her would adore each other. Had she been born a lot sooner she would be here.”
Coroner Dr Clare Keane delivered a verdict of medical misadventure and said the medical cause of death was hypoxic ischemic encephalopathy, secondary to intrauterine hypoxia.
Dr Keane added that the couple’s decision to donate Molly’s heart valves was an “incredibly generous gesture at such a very difficult time”.
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