A mother whose baby died five days after birth has said she is now satisfied that a “fair and just process was followed” after a second inquest into his death examined previously undisclosed evidence.
Claire Cullen, who cofounded Safer Births Ireland, secured evidence surrounding concerns over equipment used in her son Aaron’s resuscitation after he was delivered by emergency Caesarean section at Midland Regional Hospital Portlaoise in May 2016.
This evidence, which she obtained through freedom of information requests, sparked a fresh inquiry as it was not made available to an initial inquest which returned a narrative verdict in 2019.
A narrative verdict was returned by coroner Dr Myra Cullinane on Thursday for a second time, incorporating the new evidence, before she recommended that all information relating to a death being investigated by a coroner “be disclosed in full and at the earliest opportunity”.
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Dr Cullinane said the recommendation was made “to prevent anyone else from going through what we have had to go through”.
Providing new evidence, nurse Elaine Sheehy told the inquest on Wednesday that the flow of gas through a “Neopuff” resuscitator used to provide oxygen to Aaron during his first 11 minutes of life was at a low level until she arrived.
Unable to breathe after birth, the Neopuff resuscitator was used between two failed intubation attempts. He was ultimately intubated at 21 minutes of age once a paediatric consultant arrived.
Ms Sheehy also recalled a full-term mask being used which was too large for Aaron, who was born at 35 weeks.
After corrective actions, Ms Sheehy said Aaron’s heart rate improved and the machine began to record oxygen saturation.
However, the inquest heard on Thursday that Aaron was “already in extremis” immediately after his birth, and had been suffering from severe and persistent pulmonary hypertension, a condition in which a baby fails to transition from antenatal circulation.
This, which was noted as being caused by systemic thrombosis, was the ultimate cause of his death.
Dr Paul Downey, a consultant perinatal pathologist, said thrombosis found in Aaron’s left kidney was heavily calcified suggesting it was “well established” before birth.
The systemic thrombosis was noted as being in association with a non-lethal mitochondrial disorder, from which the inquest heard just 30 people are known to suffer worldwide.
Dr Downey said it was unclear whether there was an issue with oxygen delivery during part of the resuscitation; however, if that was the case, it was his opinion that it did not cause his death.
“That’s not to say it didn’t have any effect, but I don’t think it caused his death,” he said.
Before a verdict was delivered, Fiona Gallagher, counsel for the family, said the failure to disclose Ms Sheehy’s concerns as evidence exacerbated the “trauma and distress” the family has suffered.
Counsel for the HSE, Luán Ó Braonáin, submitted that evidence heard this week points to a death of natural causes, saying it would be in the discretion of the coroner to find such a verdict.
Speaking outside the court, Claire Cullen said her nine-year fight has “finally reached a conclusion”.
She said her son’s rights were “hindered and impacted throughout every investigative process” into his death.
Ms Cullen believed if she had not sought further information, “it would have never been disclosed to me”.
“Six years ago, we left the coroner’s court with more questions than answers,” she said, adding that she is now satisfied it has had the opportunity to be fully investigated.
“Today, I leave the coroner’s court knowing that I did everything in my power to offer my son the dignity and respect as a human being that he deserved,” she said.
