Inquest hears Baby Grace died at Cork University Maternity Hospital after 'medical mistake'
Evidence The Into Give Own (left) Charlotte Ger Kirwan Been Baby’s Heard Inquest That An External Invited (right) Have Her Also Review To Nor Husband Yet To Neither Their Death
An inquest has been told a baby died after a “medical mistake” before she was born.
This was according to a registrar who delivered Baby Grace Kirwan at University Hospital Waterford (UHW).
On the second day of her inquest at the Cork City Coroner’s Court on Washington Street, Dr Mahmoud Mustafa said the fact that Baby Grace was in the breech — bottom first — position had gone undiagnosed until he was called on to assist in her delivery on August 6, 2022.
He said that by the time he arrived in the labour ward that night and had examined her, he spotted the breech immediately. This was despite the fact that not only had a midwife come to a completely different conclusion just minutes earlier, but two other midwives had also failed to spot it.
They had all concluded Baby Grace was in the cephalic — head first — position.
Senior Counsel Liam Reidy, instructed by the Kirwan family solicitor Pat Daly of Cantillons Solicitors, asked Dr Mustafa if it was “a medical mistake” for the breech not to have been spotted. In reply, Mr Mustafa told Cork City Coroner Philip Comyn: “Yes, it should have been picked up.”
The inquest heard that Baby Grace’s body was delivered first but there had to be a surgical procedure to deliver her head. It then took staff some 26 minutes to resuscitate the baby, who suffered severe brain damage and died of hypoxic ischaemic encephalopathy.
The inquest also heard that neither Charlotte nor her husband Ger have been invited yet to give evidence to an external review into their own baby’s death. This was despite Mrs Kirwan specifically asking to be involved in any reviews into her daughter’s death on August 10, 2022, after she had been transferred to Cork University Maternity Hospital.
Senior Counsel Luán ó Braonáin, for UHW, said: “The review process has not been completed. What they might recommend is unknown to us and we are not in a position to say what might emerge.”
The inquest heard that since Baby Grace’s death, nursing staff at UHW have received “basic training” on both the use of ultrasound scans and breech presentations.
At an earlier hearing, the court heard Mrs Kirwan received an anonymous letter after her baby daughter’s death telling her mistakes had been made before Baby Grace was born.
The court also heard that maternity staff in the labour ward were afterwards “angry” about what had happened and had even urged the couple to — in effect — ask questions about her care and get an explanation about what had happened.
The fact that Baby Grace was a breech was first spotted at a scan on May 19, when Mrs Kirwan was 28 weeks pregnant, but not only wasn’t she told but also nursing staff said they were unaware. UHW Clinical Midwife Manager Aoife Keenehan said “there were no red flags”.
This was despite, as Mr Reidy pointed out to her on Wednesday that the fact that a breech position had been detected on May 19 was actually in Mrs Kirwan’s notes which staff had hours to go through after Mrs Kirwan was admitted to the hospital more than seven hours before Baby Grace was born in the UHW maternity unit.
Mr Reidy also asked Ms Keenehan to confirm Mrs Kirwan had been the only woman in active labour in the hospital in August 6, 2022, and she confirmed this.
He also asked her if “the thought of a breech crossed anybody’s mind” and she replied: “No.” He later stated in his submissions: “What lies behind (what happened) was bad decisions by people we would expect to have made better decisions.”
Mrs Kirwan, who now has a five-month-old baby boy born in CUMH, described at an earlier hearing that Baby Grace’s delivery in UHW was the most “frightening, distressing, prolonged, harrowing experience” she had ever had.
Mr Comyn recorded a narrative verdict. In doing so, he said the fact that Mrs Kirwan was not told her baby was in the breech position on May 19 was “an opportunity missed”.
He said: “There are facts that point to (a verdict of) medical misadventure. But I believe the narrative verdict is the appropriate one.”
Among his recommendations, he said that all notes should be shared with mothers and fathers.
“This may cause a burden on hospital administration,” he said. “But the benefits outweigh the disadvantages.”
Mrs Kirwan said afterwards: “I would urge all maternity hospitals to share information with expectant mothers.
“If I had been told my baby was in a breech position, I could have requested an ultrasound scan and would have.
“It is so important that there (should) be candid and open communication between the doctor, hospital and patient.”
She added: “Ger and I are relieved that the Inquest process has concluded.
“Hopefully what happened with us (will) never happen to another family.”