Coroner recommendations 'might save other families living through this nightmare'

Patrick and Hilary Murphy. The inquest heard Ms Murphy had expressed concern about her unborn son’s reduced movements and other issues up to her son’s death.

The coroner in an inquest into the death of a baby at Portlaoise Hospital has recommended maternity staff be given regular training updates on clinical and other guidelines and families be fully informed if their children's organs are retained.

The recommendations follow the recent inquest into the death of Ódhran Patrick Murphy, who was stillborn at the Midlands Regional Hospital Portlaoise, Co Laois on December 27, 2021. Odhran's parents, Hilary and Patrick Murphy, welcomed the guidelines but said they will only be satisfied when the HSE implements them. They told the Irish Examiner: “This will ensure that families like ours and many before us are less likely to go through and constantly live this nightmare.”

Coroner Eugene O'Connor recorded a verdict of medical misadventure. The inquest heard that on two occasions over an 18-hour period, staff failed to carry out four-hourly reviews of both Ms Murphy and her unborn baby.

This was despite the guidelines in place for treating expectant women like Ms Murphy, who had been admitted to the hospital having suffered from Prelabor Rupture of Membranes (PROM) — meaning her waters had broken, but she was not in labour.

The inquest also heard Ms Murphy had expressed her concern about her unborn son’s reduced movements on December 12 and other issues up to her son’s death. Odhran died from a lack of oxygen following a large placental abruption and bleed that had not been spotted in time.

Ms Murphy told the inquest she had twice asked for membrane sweeps in the two weeks before her son died and if she could be either induced or have a Caesarean section because she had a low-lying placenta.

Her consultant Dr Miriam Doyle, however, told the inquest she did not recall being asked by Ms Murphy about a C-Section, or for membrane sweeps.

Verdict

In delivering his medical misadventure verdict, the coroner said: “Some of (the) evidence is conflicting.

“I am satisfied, however, that the narrative given by Hilary Murphy is correct and consistent with her concerns before this sad event."

Ms Murphy's SC Sara Antoniotti had told the inquest: “It is all well and good having guidelines, and policies and recommendations. But it is essential that staff are aware of the content of them.” 

The coroner recommended the guideline on the management of PROM be reviewed and be “in conformity with current National Institute for Health and Care Excellence (NICE) guidelines and those of the Royal College of Obstetricians and Gynaecologists (RCOG)”.

Ms Antoniotti had asked the coroner to recommend that the hospital review the PROM guidelines, saying: “Regrettably and tragically there might have been a different outcome if the guidelines had been different.” 

The coroner also recommended that the guidelines on the management of antenatal (women) admitted for the induction of labour be reviewed and “be in conformity with” the current NICE guidelines and those of the RCOG.

Organs

In relation to the retention of her son's organs, Ms Murphy had told the inquest that the stress of having her son’s organs retained for nearly a year led to her subsequently suffering a miscarriage in the summer of 2022.

The fact that Ódhran’s organs had been retained for so long had meant that his father Paddy and Hilary had to hold two separate burials for him.

Ms Antoniotti pointed out that while a postmortem report had been completed in July 2022, there was no reference to the fact that organs had been retained.

"If organs are going to be retained, there should be some documentation about this," she told the coroner.

The coroner recommended: “In respect of the application of the HSE National Clinical Guideline for postmortem Examination Services that in respect of organ retention, communication and documentation of actions and information is required with an available point of contact for the family.” 

In response to the coroner’s recommendations, Hillary and Paddy told the Irish Examiner: “As far as the recommendations go, we are happy that the Coroner has addressed them and that they will be published.

“But we will only be satisfied when and if the HSE not only accepts them but actually implements them as soon as possible in the agreement that they can and will help to save perfectly healthy babies' lives.

“This will ensure that families like ours and many before us are less likely to go through and constantly live this nightmare.”