A verdict of medical misadventure had been returned in the case of a baby boy who died almost one week after his birth in Mullingar General Hospital in August 2014.
Dublin city coroner Dr Brian Farrell said the cause of baby Kevin Kelly's death was hypoxic ischemic encephalopathy due to intra-uterine hypoxia, or a shortage of the supply of oxygen to the brain during delivery.
Dr Farrell identified a slowing in baby Kevin’s heartbeat after a failed instrumental delivery and before an emergency Caesarean section as the main causative factor in the death.
Kevin Kelly was born in a poor condition in the hospital's maternity unit on August 16nd, 2014. Within hours, he was transferred to the National Maternity Hospital in Dublin for treatment, where he died on August 22rd.
His father, also Kevin, from Kinnegad, Co Westmeath, told the inquest his son had markings "in a very unusual place" as a result of a forceps being applied to the front of his son.
‘Too small anatomically’
He said he heard a locum registrar say before delivery that his wife Una was "too small anatomically" for a regular delivery before going on to make a number of "vigorous attempts" to use a forceps in the labour ward.
A consultant in Mullingar told him shortly after the birth that “this should not have happened”, he said.
Ms Kelly, a paediatric nurse at Temple Street children’s hospital, said she could hear the forceps “click” during the delivery attempt, but the doctor “could not get a grip”.
Before the attempt to deliver using the forceps, the baby’s heart-beat was normal, but afterwards, it slowed considerably.
Ms Kelly told the coroner that once the decision was made to send her for an emergency Caesarean, everything was “rushed and panicked” in the ward, but there was a delay in getting her to theatre.
She remembered there being “a heated exchange” between a midwife and a member of the operating team, and her epidural was not working on the left side. There was no consultant present at this stage.
The theatre then filled up with paediatric doctors and an emergency Caesarean was carried out by a locum registrar. Ms Kelly said she witnessed her son being born “limp, lifeless and in very poor colour”.
She said she was distressed and asked to be put on anaesthetic. When she awoke she became aware baby Kevin had sustained an injury caused by oxygen deprivation to the brain and was continuously seizing.
Cooling treatment
He was taken to the National Maternity Hospital for brain cooling treatment and was later reviewed in Temple Street. Ms Kelly was also transferred to Dublin.
Ms Kelly said Prof Mary King in Temple Street told her Kevin had "minimal" chances of survival and added that what had happened was not due to genetic factors but to "events around the birth".
The Kellys decided to withdraw medical treatment for their son and he died in Ms Kelly’s arms at 1.30am on August 22nd.
Dr Michael Osasare said he decided to use the forceps because Ms Kelly's delivery was not progressing. The instrument locked with ease and he gave just two pulls because he had in mind the possibility that his intervention might fail.
Eugene Gleeson SC, for the Kellys, said Dr Osasare had misapplied and "fumbled" the application of the forceps.
No responsible obstetrician would have attempted a normal delivery by forceps given Ms Kelly’s petite size and other clinical factors, he claimed.
Dr Osasare denied these claims and said he had previously carried out forceps delivery more than 20 times in hospitals in Kerry, Kilkenny and Canada.
Fully dilated
Ms Kelly was fully dilated and the baby’s heart trace was normal.
Asked about the marks in the middle of baby Kevin’s head, he initially denied these could have been caused by a forceps and suggested they could have been caused by fingers. Under questioning, he agreed it was possible they were caused by forceps.
After the failed forceps delivery, Dr Osasare referred Ms Kelly for a category 2 Caesarean, rather than the most urgent category 1 referral. He said he was unaware at this time that baby Kevin’s heartbeat had slowed by then.
“It still haunts me today, and I keep thinking what I might have done to make the situation better. It’s a nightmare but I wasn’t aware of this.”
