A lawyer for the parents of the dead baby who called for the misadventure verdict said the word “misadventure” meant “mistake” without fault and the verdict would help prevent avoidable deaths of babies in the future.
The two-day hearing in Limerick heard baby Mary Kate Kelly would have been saved if a registrar doctor at the Midland Regional Hospital in Portlaoise had acted on a electronic (CTG) test on the baby’s heart.
A midwife objected to the doctor’s decision to discharge the mother, Amy Delahunt, a teacher from Borrisoleigh, Co Tipperary.
The midwife told how her request to the junior doctor to call the on-duty consultant was not acted on by the doctor.
Ms Delahunt, a teacher in Portlaoise, became concerned about her baby on May 21, 2013, when at school.
She was almost 35 weeks pregnant at the time.
On contacting the Midland Regional Hospital in Portlaoise she was told to come in straight away.
She decided to go to Portlaoise rather than travel the hour-and-a-half journey to the Mid-Western Regional Maternity Hospital in Limerick where her pregnancy was being managed.
After a CTG test, a registrar, Dr Chuck Ugezu informed her that everything was fine and discharged her despite protests by the midwife Sally Hanford, who had been attending Ms Delahunt.
The midwife asked Dr Chuck to call the on-duty consultant, Dr Miriam Doyle, to see Ms Delahunt, and he failed to do this.
Dr Mark Skehan, a consultant gynaecologist and obstetrician at University Maternity Hospital Limerick, told the hearing he would concur with Dr Doyle’s view that if Ms Delahunt was induced at the Midlands Hospital rather than being sent home, she would have given birth to a live baby.
Dr Ugezu, known as Dr Chuck, admitted on the opening day of the inquest that he should not have discharged Ms Delahunt, given the finding of the CTG trace which monitors a baby’s heart.
When giving evidence he apologised to Ms Delahunt and her partner, Oliver Kelly.
Addressing the jury, senior counsel David Holland, for Ms Delahunt and Mr Kelly, called on them to return a medical misadventure verdict. The word “misadventure”, he said can also mean “mistake” without fault.
Nothing, he said, can undo the harm done to the couple and the tragedy that befell Mary Kate. The only thing that can be done now, he said, was to help avoid other
deaths of this kind.
The jury made a number of recommendations, including that all staff receive training on the interperetation of CTG; that the HSE promote a culture of life-longlearning for healthcare professionals; and that midwives and doctors should have clear written instructions on escalation of care.