An inquest into the death of a one-day-old baby boy in Cavan General Hospital in May 2014 has returned a verdict of medical misadventure.
The verdict in the death of Conor Whelan, who died of a brain injury caused by a rare fetal condition that went undetected, was reached unanimously by a jury of seven women and three men following three days of evidence.
The jury made three recommendations when reaching their verdict – an appraisal by the HSE of the obstetrics unit in Cavan, the immediate appointment of an obstetric radiologist in the hospital, and 20-week scanning of all pregnant women.
Cavan coroner Dr Mary Flanagan, in her advice to the jury, said medical misadventure was probably the most appropriate verdict given the evidence, but it did not imply negligence. Expressing her deepest sympathy to Conor’s parents, Siobhán and Andrew, she expressed the hope that some of their questions had been addressed during the inquest process.
Evelyn Hall, general manager of the hospital, apologised to the family and promised the hospital would implement the recommendations made by the jury.
Speaking after the verdict, Ms Whelan said her son would be alive today if the hospital had acted more promptly in their response to her risk factors. Vasa previa was detectable by modern scanning equipment, but maternity units such as Cavan often lacked such facilities.
“Every pregnant mother is entitled to a decent scan, to leave a clinic knowing for sure everything is as it should be. This should be afforded to every mother in Ireland, not by a postcode lottery.”
She said it had taken the family two and a half years to get answers, but hopefully the legacy of his short life would be to increase awareness of vasa previa. The incidence of vasa previa is less than one in 1,000, but the survival rate for a baby more than doubles when it is detected early.
Conor was born on May 13th, 2014 following an emergency caesarean, but died after 17 hours. He suffered a brain injury caused by an abnormality of the placenta known as vasa previa, where blood vessels block the entrance to the birth canal.
In her evidence, Ms Whelan told of her devastation at his premature death.
Ms Whelan and her husband Andrew, from Ballyjamesduff, said their son died after her membranes were ruptured against her will and following a delay in carrying out the section. A delay in giving him a blood transfusion after delivery is also alleged.
The hospital suggested Conor’s death was due to a substantial loss of blood that occurred before his mother’s membranes were ruptured in the hospital.
Staff acknowledged he should have received more blood in transfusion, more quickly. Cavan has no radiologists specialising in obstetric scans and does not routinely perform a 20-week fetal anomaly scan as happens in larger hospitals, it emerged during the inquest.
Perinatal pathologist Dr John Gillan, who carried out the autopsy on Conor, said the tearing of his blood vessels was the critical event that led to the bleeding, which in turn caused the brain injury and his ultimate death.
Dr Roger Malcolmson, a British perinatal pathologist called by the family, said the rupture of Conor’s vessels could have happened when his mother’s membranes were ruptured by staff. However, a spontaneous rupture of the vessel at a time earlier in labour remained a possibility.
Ms Whelan attended the obstetrics department for a scan in March 2014, and a low-lying placenta was suspected. However, a follow-up scan by a radiologist was normal. This scan failed to pick up an abnormal division of the placenta, the inquest heard. At every clinic visit, Ms Whelan asked staff to check her placenta, but was told not to worry. On one occasion she was told “are you not still going on about that”.
On May 13th, at nine days overdue, she began to experience contractions and headed to the hospital. On walking to the labour ward, she saw blood trickling down her leg and called for help. Mr Whelan begged staff to act quickly, reminding them that another baby had died in the hospital two weeks earlier.
There was “pandemonium” after the decision to carry out a section and the trolley carrying her ran over a nurse on its way to the operating theatre, Ms Whelan told the inquest.
The on-call obstetrician stayed at a weekly statistics meeting for 10 minutes before coming to theatre, where the senior midwife said a “semi-emergency” was unfolding, the inquest heard.
Vasa previa, which is extremely rare, was not considered as a possibility during the delivery. Conor was born “flat” at 1.49pm, an hour after she arrived at the hospital, and it took 20 minutes to bring him back. Ms Whelan had to undergo life-saving surgery after suffering major bleeding while her baby was brought to the Rotunda hospital in Dublin. There, doctor could find no brain activity and it was decided to return him to Cavan to spend his last hours with his mother. He died the following day.
