A Dublin couple whose baby died shortly after birth say the way they were treated by the hospital was unacceptable and it seemed as if their baby’s death didn’t matter.
Nicola Cox, who is a lawyer, and Ross Coghlan, who works at The Irish Times, feel "battered and exhausted" by the experience of trying to get answers from the National Maternity Hospital, on Holles Street in Dublin, about why their son, Luke, died.
They are “extremely grateful” for his inquest last week – a process they say they could trust.
Luke Coghlan was born at the hospital at 6.05am on December 28th, 2016. He died less than half an hour later, despite efforts to save his life.
At Dublin Coroner's Court obstetric gynaecologist Dr Aoife Morris said his death had been "completely unexpected".
Ms Cox had expressed concerns during the pregnancy about his growth and reduced movement, though scans showed Luke’s size was within the normal range.
The inquest heard his death was due to the effects of placental disease and he had suffered a hypoxic ischaemic encephalopathy – where an infant's brain doesn't receive enough oxygen and blood – about 36 hours before delivery. Coroner Dr Myra Cullinane returned a neutral, narrative verdict.
Luke’s parents accept the verdict, and that there were no detectable signs of the placental disease during the pregnancy, though they will always wonder whether, if Luke had been delivered a few days earlier given the mother’s concerns, he might have lived.
“It is sad to think I as a mother knew something was seriously wrong and we still couldn’t save him. That is heartbreaking. It does feel like the mother’s voice gets very little weight attached to it,” Ms Cox says. “But our real concern now, something we can do something about, is the treatment we got afterwards which was dehumanising, made us feel so much worse at a time of such horrific loss.”
Within half an hour of Luke’s birth, and death, and while they were still in the labour ward a consultant was “badgering” them to sign a consent form for a postmortem.
“We kept asking them to please, give us some time to think about it,” she says, “because it was a horrible thing to think about.
“He was our newborn baby. At one point they said their shift was nearly over, so we said, ‘Okay, okay we’ll sign it’.”
‘Why fight?’ They were then brought to a room where a cold cot – a refrigerated cot to help preserve a stillborn infant – was in place.
“I was holding Luke and this one midwife came in. There was no ‘hello’, or ‘sorry for your loss’, nothing. Just, ‘put the baby in the cot. He’s deteriorating. Put the baby in the cot’. I was afraid to take Luke again in my arms while she was on, in case she’d give out to me.”
A midwife who came on for the night, however, was “so kind”.
“She came in, introduced herself, said, ‘Is this your baby? Oh my, he’s beautiful. Do you mind if I hold him?’ She gave me a lovely hug and she cried a little. It’s all you want, some compassion. She was brilliant.”
The following morning, having been told the postmortem would be at noon, they waited for Ms Cox’s mother to come and say goodbye to Luke. Some time before noon, however, a midwife arrived to say: “We’re taking baby now.”
Mr Coghlan recalls: “We said, ‘Nicola’s mam is on her way. Can we just wait a few minutes?’ and we were told, ‘No. The pathologist needs him now. We have to go’. Nicola was getting frantic, saying, ‘No way you’re taking him. You’re not having him’. You’re so protective still of your baby. We just wanted to say goodbye to him while he was still perfect.”
He asked the midwife to leave because his wife was so upset. In the end they were allowed to wait for Luke’s grandmother.
There was then a stand-off over whether they could bring Luke to the pathologist or would have to hand him over to a member of staff. In the end they were allowed to carry him down.
“I just thought why are you doing this? Why fight with us?” she says. “We were in shock, in trauma, in bits, couldn’t believe we had lost our baby. I remember in the labour ward trying to breastfeed Luke, thinking if I could just feed him, if he would just latch on, my baby would come back. That is the level we were functioning at, going mad with grief, and they were just on a whole other level – not with us at all.”
‘It was horrible’
On the same day, Ms Cox, who is a barrister, shared her concerns with a senior staff member that perhaps Luke’s death could have been avoided.
“She said: ‘If you want money you could sue,’ and then commented, ‘I hope you don’t specialise in med neg.’ I just thought ‘okay, this is where the hospital will be coming from,’ which again eroded any trust we had. It was horrible.”
They returned the following day to collect Luke. He was “laid out nicely”. When they went to leave, however, they were told they couldn’t leave through the front door, but would have to use a side door into an alley.
“The lane was full of rubbish, broken glass and dog faeces. They said we had to go out that way. We said, ‘No way. We want to bring him out the front door’. It was the respectful thing to do for Luke. In the end we just refused. We brought him out the front, and that meant the world to us,” she says.
“He was in a Moses basket and just looked like he was asleep. I suppose they didn’t want people to see him, but it’s so hard. You are dealing with losing your child, and these fights. It was harrowing.”
They had a cold-cot to bring home, provided by Féileacáin. Luke's funeral was on January 4th, 2017. He is buried in Glasnevin Cemetery.
Two days later, they attended a meeting at the hospital with the then master, Rhona Mahony, and a senior obstetrician who had not been involved in their care. "It was very upsetting. Every concern Ross raised was met by a query questioning his medical knowledge. It was belittling. We left the meeting feeling distressed."
They were promised the postmortem report as soon as it was ready – within weeks. “I was frantic waiting for it,” says Ms Cox. Towards the end of March 2017, she rang the coroner’s office to see if they had received it. “They sent it to me. I had to get it myself basically. The hospital knew how much I wanted to know how my baby died. They knew it was the most important thing.”
Information
They also wanted to know the outcome of any discussions or meetings among staff, about Luke’s death. Their solicitor asked in January 2017 for all emails, meetings’ minutes and correspondence on Luke’s death and they received them in November 2017, having had to apply for them under the Freedom of Information legislation and pursue these requests all the way to the Information Commissioner. “It was such a struggle to get information. We had to fight for everything,” says Ms Cox.
They found undated, retrospective notes had been added to her file – which is contrary to protocol – by the midwife who delivered Luke, something they spotted because she had asked for a copy of her file the day she left hospital.
“You’re told your file is everything, and then to know notes were added a few days later. To think you can’t trust your notes, it’s just erodes trust even more,” she says.
“At the very worst time in our lives, when we needed support we met barriers and were treated like our grief didn’t matter, like Luke didn’t matter. We’re just battered by it. It made a horrendous journey 10 times worse.
“We are so glad of the inquest because we could trust the coroner. If we hadn’t had that we’d still be sick to our stomachs wondering what happened to our child. It could all have been done so much better.” The couple would “gladly meet” hospital management to advise them on how grieving families could be better supported.
The hospital said: “We cannot comment on individual cases. We have deep sympathy with people who have been through such a traumatic and distressing event and we work to give them all the support that we can. We sadly sometimes have to deal with people who are having what may be the most traumatic and upsetting experience of their lives.
“We seek to respond at all times with the highest standards of professionalism and sensitivity but this is not something about which we are ever complacent.”
