The death of a baby who suffered severe brain damage during birth was avoidable, a coroner has ruled.
Delivering her findings at the Coroner’s Court in Belfast on Friday, Coroner Maria Dougan said she agreed with the opinion of expert obstetricians who gave evidence to the inquest that had the baby been born by Caesarean section, he would have survived.
Troy Brady was born prematurely at 33 weeks “in a state of collapse” in Craigavon Area Hospital in August 2016 and died six days later in its neonatal unit.
He was the first child for his parents, Jane and John Brady, from Coalisland, Co Tyrone, and the coroner said the whole Brady family had been devastated by his loss in tragic circumstances and he was “missed every day”.
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The coroner outlined a number of “missed opportunities in the care and treatment” of Troy, including the failure to tell Mrs Brady that the birth was high risk and to inform her of the risks of vaginal breech delivery, which meant she and her husband could not provide fully informed consent.
There was a “subtle emphasis placed on vaginal delivery”, the coroner said, and “had Mrs Brady been properly consented, she would have, on her own evidence, opted for a Caesarean section.”
The coroner was critical of the consultant who delivered Troy, Dr Rohit Sharma, who she said “lacked the requisite experience and confidence at that time to perform a preterm, vaginal breech delivery in the all-fours position with a team inexperienced in this position for breech deliveries, and in a hospital where it had never been performed before.
“I find that Dr Sharma, who was appointed to the role of consultant six weeks prior [to Troy’s death], was attempting an unconventional technique for Craigavon Area Hospital in a potentially difficult breech birth.”
This meant Ms Brady had to be moved back into her original position on her back – known as the lithotomy position – with her baby delivered as far as his neck, which the coroner said caused delay and created “uncertainty and confusion” in the delivery room.
“Dr Sharma should have conducted the deceased’s delivery in the lithotomy position from the outset, as he was, by his own admission, not trained to conduct manoeuvres in the all-fours position.”
The baby had a chronic placental insufficiency, which meant he could not cope with a difficult birth, and the coroner said the manner and delay in his delivery deprived him of blood and oxygen and caused brain damage.
“I find that, on the balance of probabilities, had appropriate, documented counselling been given to, and informed consent obtained from Mrs Brady, and the deceased delivered by Caesarean section; had the vaginal breech delivery been conducted in the delivery team’s most familiar position, lithotomy, from the outset to avoid the delay in the change of position from all fours, the deceased’s death ... was avoidable,” the coroner said.
She recommended that all hospitals should develop a protocol around informed consent from parents during high-risk births.
A representative of the Southern Health and Social Care Trust extended their condolences to the Brady family at the end of the hearing.
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