Doctor's faulty pager delayed Caesarean - Baby inquest told.
Thursday, 20 November 2008
by Anna Maguire.
AN emergency caesarean section being carried out in a bid to save the life of Newtownstewart baby Ronan O'Brien at Altnagelvin Hospital in 2006 was delayed by up to 15 minutes due to problems contacting an on-call anaesthetist, an inquest heard on Monday.
The coroner, John Leckey, found that the newborn died from a lack of oxygen causing brain damage, after the umbilical cord became trapped during labour.
The hearing also heard that vital Cardiotocograph (CTG) records - monitoring the foetal heart rate - had since gone missing and have never been recovered.
Retired professor of obstetrics and gynaecology at Queens University, Professor William Thompson told the courthouse the baby's "condition at birth may have been less severely compromised ... if the infant had been delivered 15 minutes earlier".
“Time is of essence", he said. "Minutes really do count."
His views complied with those expressed by another expert witness, Professor Sabarantnam Arulkumaran of the obstetrics and gynaecology department of St George's Hospital, London, who said in a report read to the court that "a caesarean section... available 10 minutes earlier... might have resulted in a baby in a much better condition".
Ronan O'Brien, from Mourne Park, Newtownstewart, died 24 days after his birth at Altnagelvin Hospital on August 19, 2006.
The inquest into his death was one of four carried out into the sudden deaths of four babies at Londonderry's Altnagelvin Hospital in a six week period that year.
‘Stillborn'
The inquest held in Londonderry Courthouse on Monday heard that baby Ronan was essentially stillborn at birth, with a heartbeat not being established until seven minutes after his birth. In the interim he was deprived of oxygen.
Professor Thompson also expressed concern that the two, or possibly three, CTG traces taken prior to the baby's birth have since gone missing.
The court heard that despite exhaustive searches by the Trust, files considered vital in reviewing the care a patient received, were misplaced. Professor Thompson said he had never before come across a situation where foetal heart rate records had gone missing.
Giving evidence to the court on Monday, staff midwife Catherine De Lacy said she could think of "no reason at all" why the CTG traces had gone missing, while midwife Beverly Hanna replied, "Yes I was", when asked by Coroner Leckey if she was surprised when she heard the files had been misplaced. Both women dealt with Mrs O'Brien on the night of her baby's birth.
Professor Thompson said such records are usually kept for 25 years, adding "fine detail" was important "when it comes to looking at a case like this".
“They are a very important part of the record", Mr Thompson said. "They definitely make a huge difference to the assessment of cases like this. It's very sad in this particular case that they went missing."
An issue central to the missing CTG's was whether Mrs O'Brien should have received a continuous CTG trace following a 20-minute trace earlier in the night.
‘Decelerations'
Referring to fluctuations in the baby's heart rate shortly after Mrs O'Brien's admission to hospital as "some evidence of decelerations", Mr Thompson said continual electronic monitoring before, or at latest after, Mrs O'Brien's transfer to the labour ward would have been "good management".
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Such an intervention, he said, "may have detected evidence of foetal distress up to one hour prior to the prolapse of the umbilical cord".
His views were echoed by Professor Arulkumaran, who said in a report: "Because of the fluctuation of the FHR [foetal heart rate], if a continuous CTG was available, the changes may have indicated the need to intervene earlier. The missing CTG is essential to verify this possibility."
Professor Thompson, however, added that he was "speaking retrospectively" and that such monitoring would have been "very, very good management".
The inquest was told staff rushed Alison O'Brien to the operating theatre when it became apparent an umbilical cord prolapse had occurred.
However, while Dr Kenneth Nathan -the surgeon who carried out the caesarean section - was scrubbed and ready to carry out the operation, problems with contacting the on-call anaesthetist via pager led to the emergency operation being delayed.
Dr Karen McGrath, the on-call anaesthetist on the night, who now works at Liverpool's Alderhay Hospital and did not give evidence at the inquest, said in a statement read to the court that she had been given a temporary pager while her normal one was being fixed.
New System
Sister Kathleen Fitzsimmons told Coroner Leckey a new system has now been installed in the hospital as a result of the incident.
Speaking on Monday, Dr Nathan said he called the on-call consultant, but as he did so Dr McGrath arrived. The baby was then delivered within the minute - 27 minutes after the cord prolapse was first detected - which remains within national guidelines governing such emergencies.
Returning to a verdict of death based on the medical evidence, Coroner Leckey pointed to a number of key issues.
Referring to the absence of one of two, or possibly three, CTG traces, Mr Leckey said: "Despite an intensive search by the hospital authorities neither the trace nor the envelope for holding it has been found and their disappearance cannot be accounted for.
“I share the concerns expressed about the disappearance of such an important part of the medical record."
Citing a number of key issues raised baby Ronan's death, he added: " One, if Baby Ronan had been delivered by caesarean section 15 minutes earlier the outcome may have been more favourable and Baby Ronan may have survived; two, the reasons for the delay in contact being made with the duty anaesthetist; three, the missing CTG traces and the absence of any explanation for that; and observed and recorded fluctuations in the foetal heart rate may have pointed to the need for CTG monitoring from 03.00 hours or, at the latest, from the time the mother was transferred to the Labour Ward at 03.45 hours."
Responding to the Coroner's findings outside the court on Monday, Mrs Alison O'Brien said they would "not change what happened to me".
‘Awful'
Standing beside her husband, Martin O'Brien, she said: "It is, however, unfortunate that my awful experience brought about changes in hospital policy and guidelines that I would have expected as a minimum in the care I should have received.
“I just hope no other family would have to experience what we have gone through and hope that all the staff involved in the birth of children take on board the findings of the coroner today."
Meanwhile, a spokesperson for the Western Health and Social Care Trust said they "fully accept" Mr Leckey's findings.
In a statement to the Strabane Weekly News on Tuesday, a spokesperson for Western Trust said: "The findings announced are fully accepted by the Western Trust. The Coroner's findings reflect the opinions and conclusions in the internal and external reviews already undertaken and commissioned by the Western Trust. The recommendations made in these reviews have been implemented fully by the Trust.
“The Western Trust acknowledges and regrets that the CTG tracing is missing. When this became apparent an extensive search was carried out within the department, however, despite this the missing trace has not been located. The Coroner was informed at the time and was updated with the progress of the searches.
“A CTG machine with a facility to store electronically is now in use within the Maternity Department in Altnagelvin, this includes foetal assessment and the ante natal ward. This machine is also linked to a central monitoring system in the delivery suite to ensure that an electronic backup facility is in existence for all CTG's."
The statement added: "The Trust has also introduced an emergency contact system for the on-call anaesthetist. A 'baton' bleep specifically for alerting the anaesthetist to maternity services had been established to ensure timely contact is made. This single bleep is passed between the on-call anaesthetists to prevent discrepancies in contacting the relevant staff.
“The Western Trust would like to take this opportunity to offer its condolences to the family at this time."
