A verdict of medical misadventure had been recorded into the death of a baby after a inquest heard there was a “litany of failings” in attempts to resuscitate the girl in the first critical 15 minutes of her life following her birth at University Hospital Galway.
Lawyers for the baby’s family also claimed there was a failure to identify and escalate issues during her mother’s induction and labour which had resulted in an “entirely preventable” death.
The baby girl, Catherine Rose Hurley, died at the Rotunda Hospital in Dublin on October 17, 2020 – three days after her birth at UHG.
Counsel for UHG, Luán Ó Braonáin SC, read out an apology on behalf of the hospital’s general manager, Chris Kane, to the baby’s parents Marie Donnellan and William Hurley at the conclusion of a two-day inquest at Dublin District Coroner’s Court last week.
“We fully appreciate that no words can lessen your suffering at the subsequent loss of Catherine but wish to offer you and her extended family our deepest sympathies,” said Mr Ó Braonáin.
The same apology had been issued in January 2024 to the couple following related civil proceedings taken against the HSE in the High Court.
The inquest heard that the normally formed baby, who had no genetic defects nor any infection, had died as a result of severe brain damage due to a lack of oxygen.
However, pathologist Emma Doyle said it was impossible to state with any certainty when the injury occurred but it was likely to have been around 72 hours before the baby died.
Dr Doyle said a hypercoiled umbilical cord and abnormality with the blood flow from the placenta were contributory factors but were unlikely to have directly caused the baby’s death.
UHG did not oppose a submission by counsel for the family, Allanah McGurk BL, that the appropriate verdict was one of medical misadventure.
Mr Ó Braonáin also stated that he would not cross-examine the evidence of the baby’s parents, although he pointed out that it was clear that there were “differences of perspective and recollection.”
Ms Donnellan, a well-known Galway businesswoman who was on her first pregnancy, told the inquest that it was planned that she would be induced at UHG on October 13, 2020.
She recalled being assured by hospital staff that CTG readings to monitor the foetal heartbeat were fine after she had informed them that she could not feel her baby moving.
The inquest heard she suffered severe pain, cramps and bleeding during the day.
Ms Donnellan said a consultant gynaecologist, Úna Conway, “dismissively” agreed to give her an epidural after she had begged for one at 7.30pm.
She complained that the consultant did not carry out any physical examination of her at the time.
Shortly before midnight, Ms Donnellan said a doctor informed her that her baby would need to be delivered quickly and she recalled hospital staff were “gathered around in a panic.”
She said her baby was limp and covered in blood after she was delivered at 12.16am on October 14, 2020, while she was incorrectly informed that she had given birth to a boy.
Ms Donnellan said she continuously asked if her daughter was OK but got no answers.
She told the coroner, Aisling Gannon, that she and her husband were left waiting for lengthy periods alone before they were told at 1.45am that their daughter was very sick and being transferred to the Rotunda.
Ms Donnellan said that Dr Conway was “very defensive” when she subsequently met them and stated she did not know what could have been done differently.
She fought back tears as she recounted how she was allowed to hold Catherine for the first time shortly before her daughter died in her arms at 9.03pm on October 17, 2020.
Her husband outlined how she was “screaming and terrified” at the delivery during which she lost up to 1 litre of blood.
Mr Hurley became briefly emotional as he stressed that “the panic that was in that room does not come through in our statements.”
“All was relaxed until everything went terribly wrong and nobody was ready,” he added.
The inquest heard how he had to choose between staying with his wife or going with their daughter to the Rotunda and how he had cried the whole journey from Galway to Dublin.
In reply to Mr Ó Braonáin’s remark that there were differences between the recollection of the couple and hospital staff, Mr Hurley stated he had had a “vivid memory” and was “100 per cent certain of my statement.”
Evidence showed such differences included details about the examination of Ms Donnellan by Dr Conway as well as the timing when midwives were aware of pain and bleeding being experienced by the patient.
Mr Hurley said he and his wife only wanted that nobody else would have to experience what they went through which he described as “absolutely horrific” with one image from the delivery ward “burnt on my head.”
He said they had not realised until their other daughter was born over a year later what they had lost with Catherine’s death.
Evidence was heard from a large number of hospital staff who outlined how Ms Donnellan’s labour had progressed quickly and unexpectedly just before midnight.
The coroner was told there was “an urgent, acute event” after a sudden drop in the foetal heartbeat at 11.45pm.
In evidence, Dr Conway said she increased the frequency of ante-natal visits to clinics by Ms Donnellan because her baby was smaller than normal.
The consultant, who was treating Ms Donnellan as a private patient, said she had no concern about her vomiting after being induced as “everything else was normal.”
In reply to questions from the coroner, Dr Conway said she felt the mother and her baby were safe despite being informed that Ms Donnellan had been extremely distressed during the early stages of labour.
She recalled being updated about the patient’s condition at 9.45pm and advising that Ms Donnellan should be assessed over the following two hours.
Dr Conway said she returned to the hospital for an immediate delivery after being alerted shortly after midnight about an “un-reassuring” reading on the foetal heartbeat.
She recalled that during the pandemic was “a very, very challenging and scary time for first-time mums.”
Several hospital witnesses also became tearful during their evidence with some making a reference to the “profound effect” of the baby’s death.
Ms McGurk said the baby’s parents had sought systematic changes to policies and procedures at UHG to prevent any more avoidable deaths.
The barrister said the couple had welcomed the hospital’s engagement in the process and they acknowledged that various recommendations had been adopted and implemented by April 2024.
Recording a verdict of medical misadventure, Ms Gannon said the inquest had been a “harrowing experience” for the deceased’s family and she also commended them for the “extraordinarily impressive dignity and integrity” they had shown.
The coroner also acknowledged the profound effect that the circumstances of the baby’s death had on staff at UHG.
Following the inquest, the couple thanked the hospital for the tangible progress that had been made and for its interactions and openness on implementing changes.
“Our sole concentration since Catherine’s tragic, senseless and life altering loss has been on working directly with the relevant stakeholders to achieve measurable, cultural and systemic change at UHG,” they said.
However, they also expressed disappointment that elements of the inquest included depositions by hospital staff which appeared “inconsistent with the constructive and transparent progress we have made with the hospital.”
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