Baby died after ‘traumatic’ delivery into toilet at Rotunda, inquest hears

Open verdict returned as Dublin maternity hospital admits monitoring policy was not followed ‘to the letter’

96/1/96       JOE ST LEGER           11 JAN 1996 THE ROTUNDA HOSPITAL, DUBLIN

A baby girl was delivered into a toilet in the Rotunda Hospital by her mother and died 10 days later after the mother’s sister and a nurse had struggled to prevent the placenta and the baby’s umbilical cord from being flushed down the toilet, an inquest has been told.

An open verdict has been returned at the inquest of baby Sarah Virlan, who was delivered by her mother Mirela in a bathroom in the hospital on November 26th, 2019. She was taken to intensive care but had suffered severe brain injury and died on December 6th.

Ms Virlan, whose membranes had ruptured earlier in the day, gave birth to Sarah unexpectedly during a visit to the bathroom to change pads following the breaking of her waters.

Normal pregnancy

Ms Virlan, who came to Ireland from Romania in January 2019, had a normal pregnancy until she experienced pains on November 25th that year.


The following day, when the pain intensified, her sister-in-law Luliana Serban called an ambulance and the two women were taken to the Rotunda. Ms Virlan was given a bed and staff say she did not communicate any sign of labour or distress over the hours through the day.

Ms Serban told the inquest she asked “constantly” for staff to check on her sister-in-law. They should have checked whether she was dilated, she said.

Later, Ms Virlan’s waters broke and a nurse advised her to go to the bathroom. Sitting on the toilet seat, she experienced the sensation of her waters continuing to break, according to her statement. After four or five minutes, she saw blood and flushed the toilet. At this point, she saw the leg of her baby Sarah in the bowl.

Ms Serban said she saw the placenta after Ms Virlan stood up from the toilet and flushed it, as the water disappeared down the bowl. She said that instinctively, she grabbed it “with a scooping action”. The two women then shouted for help.

Staff midwife Karen Behan said she heard Ms Serban calling for help at 8.58pm. When she got to the bathroom, she saw Ms Serban between the sink and the toilet with the baby in her hands. The baby was limp, cold, grey and wet.

She could not leave the bathroom with the baby because the umbilical cord was going down the toilet. There was traction on it and it was connected to the placenta, which was “around the bend”. Ms Serban took out the placenta and they brought the baby for resuscitation.

Intensive care staff immediately commenced cardiopulmonary resuscitation (CPR) and intubation. After 20 minutes, they ceased CPR and were about to pronounce Sarah dead when a slow heartbeat was found. However, she did not recover and died the following month.

The Rotunda has a policy that family members should not be used as interpreters but this was not followed in this case because Ms Serban was willing to provide translation.

Delivering an open verdict, Dublin city Coroner Clare Keane gave the cause of death as hypoxic-ischemic encephalopathy (HIE — lack of oxygen to the brain), secondary to foetal vascular malperfusion and ascending infection.

Dr Keane said it was difficult to understand clearly what the nature of Sarah’s death was.

Some issues had not been clarified in evidence, such as who had removed the placenta from the toilet and whether Google Translate was used to communicate between staff and Ms Virlan and her sister-in-law.

“It was an absolutely traumatic event for everyone involved and that may be the reason for the conflicting versions,” said the coroner.

Monitoring patients

While acknowledging the “exceptional” work done by midwives and doctors, she said it was at the busiest times that staff needed to use the objective tools for assessing patients that are available.

Conor Halpin, for the Rotunda, had earlier acknowledged the hospital’s policy on monitoring patients had not been followed “to the letter” in the case of Ms Virlan.

“However, we simply don’t know if a lack of monitoring, or delivery in an alternative manner, would have made any difference,” he told the inquest.

“The hospital has apologised to the parents of baby Sarah for any aspects of care that may have contributed to the death of their baby girl and has acknowledged the emotional distress suffered at the time of her birth and her death,” he said.

The case has been reviewed by a senior management team, which has recommended more staff education on monitoring signs of early labour and the use of the hospital’s 24/7 interpretation service, Mr Halpin added.

While Ms Virlan filed a statement to the inquest, she declined to attend the inquest, saying she has no intention of returning to Ireland after what happened. She has since given birth to two more children.

Paul Cullen

Paul Cullen

Paul Cullen is Health Editor of The Irish Times