A newborn baby died after hospital staff had difficulty inserting a tube into his airway to assist his breathing.
Baby Nathan Kranjcec was not breathing when he was born at the Coombe Hospital in Dublin at 12.30am on June 5, 2017. He was pronounced dead 45 minutes later.
Parents Katarina and Valentino Kranjcec, originally from Croatia but living in Dublin, said the loss of their first baby together left them devastated.
"We are absolutely heart-broken over the loss of baby Nathan. Our world has fallen apart," the parents said, through their solicitor.
The couple said they found the process of gathering answers following the death of their only son very difficult "with no end in sight".
Dublin Coroner's Court heard that baby Nathan was considered a high risk delivery because he was underweight and had a heart defect. A post-birth cardiac procedure was expected to save his life.
Katarina Kranjcec was 37 weeks pregnant when she arrived at the Coombe at 3pm on June 4 2017. Her waters had broken that morning. She was assessed and brought to the ante-natal ward. A CTG test revealed the baby’s heart was beating normally at 6pm.
The baby’s heart rate was checked again at 11.45pm and was found to be abnormal at first before returning to normal. Mrs Kranjcec told her midwife she was concerned because the baby had not moved since around 6pm.
“When I went to her bedside, I asked her if she was feeling okay. I asked if the baby was moving as normal. She (the mother) reported the baby was quiet and said this would normally be the baby’s busy time (for moving around),” midwife Tara Fakhry said.
Asked if anyone interacted with Ms Kranjcec since the previous check at 6pm, the midwife said not to her knowledge.
Ms Fakhry said it was a busy night and no staff had time for a break all night.
There was our usual allocation of staff but sometimes during the night we don’t have time to stop for 12 hours.
The midwife called a doctor to review the latest CTG reading and a decision was made to bring Mrs Kranjcec to theatre for a Category Two emergency Caesarean section.
Baby Nathan’s heart rate was detected in theatre four minutes before he was born at 12.30am, but he was not breathing at birth.
Attempts were made to intubate and ventilate the baby but 22 minutes passed before these attempts were successful.
Baby Nathan’s condition once ventilated did not improve and he was pronounced dead at 1.15pm.
A post-mortem gave the cause of death as hypoxia due to the inability to ventilate immediately after birth, the cause of which was undetermined.
Coroner Dr Myra Cullinane returned a narrative verdict and offered condolences to the baby’s parents.
“I hope that whatever we have been able to establish here, it’s made things a little clearer for you, but we are still not completely sure exactly what happened and why it was so difficult to help his breathing,” the coroner said.