THE MOTHER of a 22-day-old baby boy who died in Altnagelvin hospital in Derry in September 2006 has supported calls by Northern Ireland's senior coroner to have maternity staff retrained in the use of cardio-tocograph traces (CTG), which monitor foetal heart beats.
Shirley McClean's son Kyle Robert Parke was one of four babies who died in the hospital's maternity unit shortly after they were born in a six-week period in August and September 2006.
An inquest on Monday found that the baby's death was caused by severe brain damage arising from an infected placenta.
At the inquest, senior coroner John L Leckey said a common aspect of all four deaths was the failure of maternity staff to recognise and properly interpret cardio-tocograph tracings of a pathological nature which required an immediate Caesarean delivery.
Instead, in all four cases, labour was allowed to continue as normal.
"If that happened once it might be regarded as an unfortunate one-off situation, but where there is a few instances of a failure to interpret correctly CTG traces, it makes me sit back and ask why that should be," said Mr Leckey.
He said he would write to the North's chief medical officer, Dr Michael McBride, urging him to take steps to ensure that medical staff in all of Northern Ireland's hospitals were constantly retrained in how to accurately interpret the graph readings.
Ms McClean, Rossdale Park, Waterside, Derry, said yesterday it was regrettable that four babies had to die in Altnagelvin hospital before the issue of accurately interpreting the CTG readings was highlighted.
"My pregnancy with Kyle was normal all the way until I got to Altnagelvin hospital. I had had a miscarriage two years earlier in Lanzarote when on holiday with my partner Robin Parke. We didn't know then I was pregnant but after the miscarriage we were determined to have a family," she said.
"Everything was normal until I was being induced. I could see from the midwives that they were concerned about something. Kyle never left the hospital after he was born severely brain damaged.
"He spent his life in a ventilator. We knew he had no hope of surviving and we agreed with the medical advice to have the ventilator withdrawn 22 days after he was born and he died in my arms.
Ms McClean, who has a 14- month-old daughter Cara-Louise, said lessons must be learned from her son's death.
"I was really nervous when I was pregnant with Cara-Louise because of what happened to Kyle. She was delivered by Caesarean section and if that had been done immediately in Kyle's case, we now know he might have survived, although he would have been severely brain damaged.
"I am glad the hospital has now taken steps to ensure this can't happen to another mother and I hope the chief medical officer responds in a positive way to the coroner's comments," she said.
Paediatric pathologist Dr Caroline Gannon told the inquest into Kyle's death that he had an infected placenta and did not have a heartbeat on delivery.
"Clinically, he was severely brain-damaged because the brain had been deprived of oxygen. He died at 22 days of age after the ventilator was withdrawn with the consent of his parents," Dr Gannon said.
Prof William Thompson, professor of obstetrics and gynaecology at Queen's University Belfast, who was commissioned by the coroner to investigate the death of baby Kyle, said that "no definitive action was immediately taken" after the CTG tracings were discovered.
"Caesarean section delivery should have been performed. In the event, labour was allowed to continue for a further five hours until the normal delivery occurred. An earlier delivery might have improved the prognosis," he said.