A nurse who was involved in the resuscitation of a baby who died five days later has said she was “extremely concerned” after finding that oxygen flow through respiratory equipment used was initially at a low level.
A sitting of Dublin District Coroner’s Court heard on Wednesday that nurse Elaine Sheehy raised concerns that the flow of oxygen was at a low level for the first 11 minutes of Aaron Cullen’s life.
Ms Sheehy, who resigned from her post at the Midland Regional Hospital Portlaoise in October 2016 and took up a post elsewhere, was on duty at the Special Care Baby Unit when she was asked to urgently attend resuscitation efforts.
Aaron had been born by emergency Caesarean section on May 4th, 2016, at 35 weeks gestation. The inquest heard he was “extraordinarily” unwell after his birth and was “gasping” for breath, witnesses said.
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He suffered from severe persistent pulmonary hypertension, a condition in which a baby fails to transition from antenatal circulation.
Two attempts to intubate him after birth by a paediatric registrar were unsuccessful. Between attempts, a Neopuff resuscitator was used in an effort to pump his lungs.
Aaron was 11 minutes old by the time Ms Sheehy arrived, she said, recalling the mask being used to ventilate him being too large, as it was for full-term babies.
It was then switched to a preterm mask, which was readily available in the room, to ensure an airtight seal so no gas could escape.
Ms Sheehy further recalled being “extremely upset and concerned” at the fact that she had to increase the oxygen flow of the Neopuff used during resuscitation.
Although she could not be certain, she said she either had to turn on the flow of gas providing oxygen entirely or she at least needed to it turn up to recommended levels.
Ms Sheehy, who became visibly upset while giving evidence, said she found the fact that she had to adjust the flow “very upsetting”.
While Prof Colm O’Donnell, a consultant neonatologist and expert witness who reviewed the case for the coroner, said he could not definitively say whether or not the Neopuff gas flow was turned on, it was his opinion that it was.
He cited several staff being in attendance before Ms Sheehy arrived, saying they reported checking the equipment before Aaron’s delivery.
He also noted that although Aaron did not breathe spontaneously, his heart rate increased from less than 60bpm to over 100bpm, which indicated the machine had some effect.
Prof O’Donnell said Aaron’s lungs were “very poorly compliant”, adding that it would have been “extremely difficult” to aerate his lungs during mask ventilation as opposed to intubation, which the inquest heard was not achieved until 21 minutes after his birth.
While sooner intubation would have allowed for an immediate and better supply of oxygen, he did not believe this, or a proper fitting mask from the beginning, would have changed the outcome.
Ms Sheehy disclosed concerns to the hospital’s interim director of midwifery, Maureen Revilles, after learning of Aaron’s death, which took place at the Coombe hospital on May 9th.
Ms Revilles, who said she expected Ms Sheehy to be a witness at Aaron’s initial inquest due to the disclosure, insisted that she said she had to turn on the machine.
This was later “revised” to her having to turn up the flow, she said.
Evidence concerning Ms Sheehy’s concerns was not made available to coroner Dr Myra Cullinane at the time of the original inquest, which returned a narrative verdict.
The evidence was secured by his mother, Claire Cullen, through Freedom of Information requests, prompting a fresh inquiry.
An inquest verdict is due to be returned on Thursday.
