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Kilkenny hospital admits failures in care of mother whose son died shortly after birth

Baby Laurence Somers died at the Coombe Hospital in Dublin on 28 January 2018.

Image: Sam Boal

A SENIOR CONSULTANT has admitted there were failures by St Luke’s General Hospital in Kilkenny in the care of a baby boy who died five days after suffering an “acute event” at his birth as well as the treatment of his mother who was 11 days overdue.

Baby Laurence Somers died at the Coombe Hospital in Dublin on 28 January 2018 after being transferred from St Luke’s following complications suffered during his delivery by an emergency Caesarean section.

Dr Trevor Hayes, the clinical director for obstetric and gynaecological services at St Luke’s, told Dublin District Coroner’s Court that he accepted Laurence was a normal baby who was delivered in poor condition.

Appearing before an inquest into baby Laurence’s death, Dr Hayes offered a sincere apology on behalf of the hospital to the boy’s mother, Gráinne Somers and her family.

Ms Somers, a mother of two other children who lives in Kilkenny, gave evidence on Monday when she criticised the lack of information provided by medical staff at St Luke’s at the time about how seriously ill their son was or that he had to be resuscitated at birth.

The consultant told the second day of the inquiry that he would not enumerate the hospital’s failings as they “would be obvious”.

However, he expressed hope that his presence in court would give the family some degree of closure.

Dr Hayes admitted that an ultrasound should have been carried out, as required under St Luke’s policy for pregnant women who were overdue by 10 days, on Ms Somers on January 22, 2018 – the day before Laurence’s birth – when she attended the hospital’s obstetrics assessment unit.

“The ultrasound should have been done, no doubt about it. The protocol is there for a reason – to be followed,” said Dr Hayes.

The consultant said it was difficult to say exactly why baby Laurence died but he noted there was evidence the boy had inhaled meconium (mucus and bile found in newborns) in his lungs which he described as having “pea soup thickness”.

While it was very easy to speculate in hindsight, Dr Hayes said the outcome might have been different if an ultrasound had been carried out on Ms Somers on January 22, 2018.

Questioned by counsel for the Somers family, Sara Antonotti BL, on whether the boy might have survived if Ms Somers had been induced on that date, Dr Hayes said he thought he would have “had a good shot that he didn’t have.”

Dr Hayes also gave evidence that he did not think Ms Somers should have been assigned to the care of a senior house officer for her pregnancy as he was “not sure she should have been put in a low-risk group.”

The inquest had heard that Ms Somers and her husband, Laurence, both had certain types of antibodies which increased the risk of anaemia in their baby. However, a scheduled check on her antibody levels was not conducted in the month before her son was born.

Dr Hayes admitted that Ms Somers’ care should have had “fingerprints of a consultant”.

He also acknowledged that every patient should see a consultant at least once during their pregnancy, even though Ms Somers had admitted it had not happened in her case.

The inquest heard several changes had been made to maternity care at St Luke’s following the tragic death of baby Laurence.

A dedicated consultant has now been placed in charge of the hospital’s obstetrics assessment unit instead of rotating staff to oversee the unit.

Patients can also only be discharged from the unit following completion of a checklist which includes that an appropriate plan approved by the patient is in place.

Dr Hayes said patients were also now facilitated whenever they wished to be seen by a consultant, while all clinics concluded with a “safety huddle” by staff to address concerns about the care of any patient.

Medical teams were also subject to “regular skills and drills,” he added.

Ms Antoniotti said her clients appreciated the openness and honesty demonstrated by the consultant and welcomed the changes made at St Luke’s.

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However, she claimed the evidence of two other doctors on Tuesday who had seen treated Ms Somers on the day before her son’s birth showed it was unclear who had been in charge of her care, while the use of an ultrasound appeared to have been optional for women over term.

The coroner, Dr Crona Gallagher, returned a verdict of medical misadventure which she said was based on the “critical evidence” of an ultrasound scan that did not take place.

If an ultrasound had been performed when Ms Somers was 10 days overdue, Dr Gallagher said its results might have led to her having an earlier delivery.

However, she stressed her finding should not be seen as a comment on the standard of care provided to Ms Somers or on liability.

The coroner welcomed the fact that many recommendations she had considered making appeared to have already been put in place by St Luke’s following baby Laurence’s death.

Dr Gallagher made the additional recommendation that all doctors and midwives should be required to undergo training on local protocols and procedures before commencing any new role in hospitals.

Speaking to reporters after the hearing, Ms Somers said the verdict had been a long time coming but they had finally got closure.

Ms Somers said she and her legal team had fought endlessly for answers about the death of her “beautiful, perfect little boy.”

“We now know that hospital guidelines were not followed,” said Ms Somers.

She added: “We hope healthcare providers take on board the importance of listening to pregnant women and their concerns and that the recommendations made by the coroner will be implemented by St Luke’s Hospital so that no other parent and family should ever have to endure the pain that we will live with for the rest of our lives.”

About the author:

Seán McCárthaigh

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