A verdict of medical misadventure has been returned in the death of a newborn baby who may have survived if he had been delivered sooner, the Cork City Coroner’s Court was told.
The court found that baby Kyle Kevin Dixon died shortly after his birth of hypoxia, which is a lack of blood or oxygen to the brain, at Cork University Maternity Hospital (CUMH) on 9 September 2020 following failings in his care during induced labour.
Baby Kyle’s mother Emma Cosgrove recounted the moments after her son was born and the frantic efforts to save him.
She told the court the only sound she heard her son make was a “gasp” which she and her husband thought was him starting to breathe.
The mother of two said she found the sound of her baby son being resuscitated so disturbing that she begged staff to take her out of the room.
“I was trying not to look at what was happening, but I just knew at that point it was taking too long and could not cope with hearing them say he was dead,” she said.
‘Multiple failures’
The court heard that the 40-year-old Ms Cosgrove, who was at high risk of hypertension, was admitted to hospital at 38 weeks on 7 September to be induced.
The inquest heard there were a number of failings in care including a failure by senior hospital staff to recognise a “pathological” trace result from the Cardiotocography (CTG) used to monitor baby Kyle’s fetal heartbeat and Ms Cosgrove’s uterine contractions during her pregnancy and labour.
An extra fetal blood sample should also have been taken after an earlier test had returned as normal but very close to the lower limits, the inquest heard.
Ms Cosgrove told the inquest, under cross examination by Senior Counsel Sara Antoniotti, that senior CUMH staff had told her during a meeting after the death of her son “that they were very sorry that multiple failures had occurred during my son’s delivery”.
She said Dr Brendan Murphy told her that for her son “to be in such a poor condition, he would have been struggling for some time”.
Consultant obstetrician Keelin O’Donoghue said Ms Cosgrove suffered from chronic hypertension but while her pregnancy was high risk, it seemed to be going well.
She said she was on call that day but not aware that Ms Cosgrove had been admitted to be induced and learnt afterwards of their loss.
She said that with an early delivery, the baby would have lived but she could not speculate on what other impacts there might have been on him.
Dr Murphy told the coroner that it is very rare to lose a baby in the labour ward.
“We usually can resuscitate,” he said.
“I anticipated him responding but it became apparent that this baby was completely unresponsive to our efforts,” he added.
Ms Antoniotti urged the coroner to return a verdict of medical misadventure.
She said the hospital had accepted that there were failures to act.
Ms Antoniotti said: “This was a high risk pregnancy, a decision was made to induce.
“Careful monitoring of that infant and mother is required, so that there can be immediate intervention if required.
“From 5am on 9 September, in a situation where there has been a suspicious abnormal and ultimately pathological trace (CTG reading) the whole point is to monitor for babies not coping with induction and intervene.”
Medical misadventure
Coroner Philip Comyn returned a verdict of death by medical misadventure.
He suggested that there should be continual professional training for staff in the use of CTG and in fetal blood sampling.
He also noted that there seemed to have been an unintentional breakdown of communication at various stages and said this needs to be looked at.
He asked: “If directions are given, who is responsible for seeing them through?”
Mr Comyn asked too if instead of referring to a patient by the room number they were in, would it not be better to refer to them by their name so that any known high risk patients would be more readily identified.
He extended his deepest condolences to the family on their loss.
In a statement issued by the couple’s solicitor Amy Langan, Emma Cosgrove and Kevin Dixon said there were multiple failings in the care provided to them during her induced labour.
It said: “If our baby had been delivered two hours earlier, he would have been with us today.
“No parent or parents should have to witness their precious baby being resuscitated – a nightmare that will always stay with us and haunts us daily.
“The loss of our precious child has left us decimated and our lives have been changed forever.”
