Couple 'heartbroken' after opportunities to save baby son's life were missed at CUMH
Rachel Harrington and Pat O’Sullivan at Cork City Coroner’s Court for the inquest into the death of their son Elijah in 2022.
A couple has told of their heartbreak after opportunities to save the life of their baby boy were missed at Cork University Maternity Hospital.
Elijah O’Sullivan died on May 6, 2022 a day after his mother Rachel Harrington presented to the hospital’s emergency department.
It was the second time she had gone to the ED because her son had either stopped moving or was showing reduced movement, Cork City Coroner’s Court heard today
Although she was kept in overnight and regularly monitored, a cardiotocography (CTG) of her baby's heart rate was later found to have been misinterpreted by one or more maternity staff.
In addition to being wrongly interpreted as “normal” instead of “pathological”, indicating a potential need for immediate intervention, such as a Caesarean Section, the CTG was also stopped.
Ms Harrington’s CUMH Consultant Dr Matt Hewitt told the inquest the CTG should not have been stopped.
He was asked by SC Sara Antoniotti, acting on behalf of the family’s solicitor Rachel Liston, if Elijah could have been born alive if the “pathological” result had been spotted and intervention carried out. He admitted it was “likely”.
Earlier, Ms Antoniotti had also asked him if Elijah was progressively deteriorating in the 11 or so hours before his death.
Mr Hewitt replied: “That is possible, with the benefit of hindsight.”
Ms Antoniotti told the court: “On the balance of probabilities, that baby would still be alive today. His was a progressive demise, he wasn’t the subject of an acute event.”
Before evidence was heard in the inquest, CUMH’s barrister Caoimhe Daly addressed Cork City Coroner Philip Comyn and said the hospital admits “there were missed opportunities” and was “truly sorry” for what had happened.
Mr Comyn recorded a verdict of medical misadventure but insisted in doing so, he wanted to make it clear this was not a finding of blame.
“The fact that the CTG was misinterpreted meant that the opportunity was lost for intervention that may well have saved his life,” he said.
“I find on the evidence before me, I believe the facts warrant a verdict of medical misadventure.”
The inquest heard CUMH — despite carrying out a review into Elijah's death — has yet to go over the misinterpreted CTG result with at least one of the maternity staff members who misinterpreted it.
Ms Antoniotti said this information appeared to conflict with a CUMH statement in evidence that the review of how the CTG result could have been misinterpreted had been “completed”.
“It appears, however, that it hasn’t been completed,” she said.
That review concluded an opportunity for intervention "which could have changed the outcome" for Baby Elijah was missed.
Ms Harrington, 27, from Douglas, fought back tears as she read out her statement about the hours and moments before her son was pronounced dead at 9.57pm on May 6, 2022.
She told the coroner: “I was 24 years of age when I became pregnant, and I am healthy and regularly active.
“I'm not a smoker and did not drink alcohol throughout my pregnancy.
“I still don't know what happened Elijah.”
She added: “Even though I was kept in for monitoring and I had told the staff there was reduced movement, I didn't think I was being treated with urgency.”
She said as a result, herself and her partner Pat O’Sullivan were so relaxed the two of them were texting their families “letting them know that we would be delivering shortly”.
After the verdict, the couple — whose baby daughter Olive was born in CUMH seven months ago — said: “As a family, we are heartbroken by Elijah's death, and have struggled to cope knowing that his death was preventable.
“We feel let down.
“We are speaking here today as we don't want any more families to endure the pain of losing a baby.
“He should be two this May, we think a lot about how different our lives would be if he was here with us.
“We miss Elijah every day and we grieve the lifetime of memories we never had the chance to create with him.”
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