Midwife told doctor to refer scan results to consultant

A midwife with concerns over a pregnant woman’s scan told a junior doctor to liaise with his consultant and told him she could not stand by his decision to discharge her, an inquest has heard.

Midwife told doctor to refer scan results to consultant

Sally Hanford, a registered midwife at the Midlands Regional Hospital, Portlaoise, only later learned that Amy Delahunt had been discharged by Dr Chuck Ugezu when she went to consult her chart. The baby, Mary Kate Kelly, was found to be dead in a scan carried out in Limerick on the following day.

Ms Hanford told an inquest in Limerick into the baby’s death, she felt Ms Delahunt should have been kept on monitoring and that she had conveyed this to Dr Ugezu.

Ms Delahunt told the inquest that, on going to her teaching job in Portlaoise on May 21, 2013 she did not feel the usual lively movement of the baby.

She rang Midland Regional (Portlaoise) Hospital and was told come in straight away for a scan.

When being assessed in the maternity unit, she felt a kick from baby Mary Kate and was given a CTG trace scan which monitors a baby’s heartbeat. She was aware that the baby’s heart beat had dropped.

Ms Delahunt was then seen by Dr Ugezu — referred to as Dr Chuck — who did an ultrasound and said he could see the baby’s heartbeat. He reviewed the CTG scan trace and told her everything was fine and the scan was normal. He told her as she had a pre-arranged appointment for the Regional Maternity Hospital in Limerick, the following morning, she was free to go.

He told her it would be normal at that stage of pregnancy for the baby’s movements to slow down and if she did not feel any movement over a 12-hour period, she should go to Limerick.

Ms Delahunt said: “He told me everything was fine and never ever suggested I should stay (in Portlaoise Hospital) and there was no cause for concern.”

The following day, May 22, she and her partner Oliver Kelly went to Limerick Regional Maternity Hospital. On telling a midwife in Limerick what had occurred at Portlaoise the previous day, she was immediately scanned and was told the baby had died. The still born baby was delivered some days later.

As they tried to find out what happened it was arranged the couple met the consultant in Portlaoise, Dr Miriam Doyle.

She said Dr Doyle had told her consultant in Limerick she could not understand how the junior doctor dealing with Ms Delahunt had not contacted her to inspect the CTG scan.

This was extremely upsetting as they thought something natural and unavoidable had happened to Mary Kate. Now they were finding something had been missed and realised her death could have been avoided. She kept saying to herself “why, why” did I go to Portlaoise and not Limerick and they would have their little girl. But she felt she took the right decision to go to Portlaoise hospital that day when she became concerned at work.

She said at their meeting with Dr Doyle, the consultant said the trace on the CTG scan was abnormal and she should not have been discharged.

Ms Delahunt said Dr Doyle informed the couple she was in the hospital that day and could not understand whey the doctor had not come to her with the scan trace. Dr Doyle seemed gobsmacked and told her Amy was let down by the hospital. She said Dr Doyle told the couple, had she been alerted, she would have delivered the baby and while she could not guarantee Mary Kate would have been healthy in every way, she would be alive.

She said Dr Doyle told them measures which had been taken as a result of what had occurred. Ms Delahunt said this was a huge relief as they had made a promise to Mary Kate they would find out what had happened so that no other parents would have to go through what they had gone through because of human error.

In her evidence, Dr Doyle said in relation to her conversation with Ms Delahunt and Mr Kelly that when she told them she had never seen a case like this before, what she meant to convey and was crystal clear was she had never come across a case where a woman was allowed go home against a background of CTG case like in this case and the baby died.

The inquest continues.

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