A husband and wife wept as they recalled bringing their baby home in a tiny white coffin after his death from a devastating brain injury suffered during birth,.
Baby Eli Hunt’s mother, Krystle, said: "It breaks my heart to know I kept my baby safe for nine months. I ate well and did all the right things. He was a big, beautiful baby and his body and organs were perfectly formed.
"I brought my son home in a tiny white coffin. This was not how I imagined bringing my first-born home."
Mrs Hunt was speaking at Cork City Coroner’s Court yesterday during an inquest into her son’s death which returned a verdict of medical misadventure.
Coroner Philip Comyn heard how Eli Hunt, from Tramore in Co Waterford, was born following emergency C-Section at University Hospital Waterford (UHW) at 6.23am on October 18, 2016, was resuscitated, and transferred in critical condition within hours to Cork University Maternity Hospital (CUMH) where he died on October 31.
He died from brain damage due to an inflammatory response due to ascending amniotic fluid infection due to the Group B Streptoccocal infection - an infection present in about 25% of all pregnancies.
Ms Hunt, a first-time mother who was deemed a high-risk patient, told the inquest that she and her husband, Trevor, were delighted when they discovered she was eight-weeks pregnant in February 2016.
The pregnancy was routine and uneventful and Ms Hunt said she felt the healthiest she had been for years.
She felt contractions around 6pm on October 17, and presented at WUH around 11pm.
Mr Hunt said he told medical staff in the labour ward that his wife had a ’strep b infection’ and Ms Hunt said as the pain became unbearable, she felt cold and was shaking, but that as a first-time mother, she felt this was normal and due to nerves.
Midwife Grace Hunt said she recalled being informed of the Strep B issue, that Ms Hunt was classed as ’high risk’, and intravenous paracetamol and augmentin were administered.
But Ms Hunt was given an epidural and two top-ups despite having sepsis. A screening report for sepsis did not appear on her medical chart.
Midwife in charge, Margaret Lyster, said she felt that Ms Hunt should be reviewed by the registrar, Dr Sara Muddasser, with a view to inducing her at 1.40am.
But Dr Muddasser, who was seeing other patients, did not review Ms Hunt and advised that the labour progress naturally.
Ms Hunt’s waters were broken at 3.30am and grade three meconium - the most alarming grade - was noticed.
But at 6am, the baby’s heart rate dropped suddenly and Ms Hunt was rushed to theatre for an emergency C-section performed by Dr Muddasser.
Consultant Paediatrician, Dr Animitra Das, said Eli had no heart rate and no respiratory effort at birth and had to be resuscitated and intubated.
He said he told the parents what was being done to their son to "prevent death or disability" but the parents said they didn’t realise Eli had a severe brain injury before he was transferred within hours to CUMH for specialist full-body cooling.
Ms Hunt said she was told that she could wait several days for a medical transfer, or make her own arrangements to get to CUMH
She was driven to Cork by her parents.
"I was given no advice on how to travel or what to do if I felt sick.
Needles were not removed from my arm. I was just given an envelope with forms in it. I didn’t know any different, I thought this was normal," she said.
Doctors at CUMH then gave them the devastating diagnosis that Eli had suffered irreparable brain damage.
"We were told there was a minimal chance he would survive, and that if he did, he would not speak hear, talk, walk, swallow and may need breathing help. I knew then we would lose Eli," Ms Hunt said.
"We spent every waking minute with Eli. We took his ventilator off on the Friday evening and prepared ourselves for minutes with him.
"But our perfect little man fought with no help for nearly three days. During this time we had to watch our baby turn blue and gasp for air, each time scared this would be it, and then he would pull himself out of it.
"On Monday night, October 31, Eli passed away in our arms. He went peacefully."
She said if she had known about the sepsis diagnosis before labour, she would have shouting from the rooftops to "get my son out because he wasn’t safe".
Mr Hunt said those days in CUMH were the toughest of his life.
"Seeing my baby fight for his life - I never felt so useless in all my life. We spent as much time as we could with Eli. But the brain injury was so severe," he said.
He said when they took Eli off the ventilator on the Friday night, there was little hope that he would survive the night.
"But he proved everyone wrong. He fought for two days. We watched him stop breathing, turn blue, gasp for air several times, and on Monday night, after a peaceful day, our little angel drifted away," he said.
He said the following days were a blur before he remembered carrying his son home in a tiny white coffin on his lap.
"My life has been torn apart. I feel I will never recover from this," he said.
Dr Muddasser told the inquest that it was a particularly busy night in the labour ward, with several high-risk patients.
She said she wasn’t aware that Ms Hunt was a defined high-risk category patient, hadn’t been made aware of the patient’s "complete picture", and that if she had more information, it may have caused her, later in the morning, to intervene sooner.
She said it was the first time in her career that she was involved in a case in which a baby had died and that she now believes she should have contacted the consultant on call earlier for an opinion.
"Not a day has passed that I haven’t reassessed my decisions. I came to work that night never expecting tragedy to occur. Decisions were made on the night which turned out to be incorrect and I will have to live with that for the rest of my life," she said.
Consultant obstetrician, Dr John Bermingham, who was not on duty that night, told the Hunts yesterday that other labour wards were far busier that night and that staffing levels at UHW were not an issue.
"I believe in good training and common sense and picking up the phone to discuss when things are not straightforward. And that didn’t happen in this case," he said.