‘We left the hospital looking for a graveyard,’ grieving parents tell inquest

The parents of a baby stillborn at the Rotunda Hospital have said part of them died the day their baby son died.

Cintia Reina and Alan Chagas, originally from Brazil but living in Phibsboro, Dublin 7 have said they want to make sure another baby does not die in similar circumstances.

Their baby Arthur Reina Chagas was born unresponsive at 8.59pm on March 28th, 2018.

A verdict of medical misadventure was returned at an inquest into the baby’s death at Dublin Coroner’s Court on Tuesday.

The baby’s mother said she repeatedly asked for the baby to be delivered by Caesarean section because her baby was in distress.

“We went to the Rotunda to have our baby Arthur but we left the hospital with empty arms and looking for a graveyard,” she said.

“I asked for my baby to be delivered by C-section many times but nobody listened to me and my baby died in my belly.”

She said cardiotocography (CTG) traces “were not read properly when our baby was in distress”.

“Things must change, babies cannot keep dying. Something needs to be done. We have lost our son and we want to make sure that this doesn’t happen again. Part of us is dead since our son died and we feel we die a little more every day,” Ms Reina said, speaking after the inquest.

Too busy

A resumed inquest into baby Arthur’s death heard the consultant on call was not contacted and the senior registrar was too busy to review the baby’s condition in the lead up to his birth.

Senior Registrar Dr Mohamed Elshaikh, told the inquest he was “too busy with other patients”. Asked why he did not contact the consultant on call, he replied: “I didn’t call him.”

The inquest previously heard that obstetric staff were busy with an instrumental delivery during this time. Two separate midwives said they did not inform the consultant on call. Both said they were waiting for doctors present on the ward to become available to assess Ms Reina.

The baby’s heart rate dropped to a dangerous level by 8.43pm. Baby Arthur was stillborn following an emergency Caesarean section performed at 8.59pm.

An autopsy found the baby died due to an acute hypoxic event between four and six hours before delivery. The cause of this event is not known.

The inquest heard of complications relating to electronic note-taking systems at the hospital.

Master of the Rotunda Hospital, Professor Fergal Malone, admitted there were inefficiencies in the electronic system but said overall, its introduction had brought a ‘significant increase in efficiency’.

Prof Malone outlined a number of changes implemented at the hospital since the baby’s death including ongoing education on the electronic note systems and the implementation of regular ‘patient safety huddles’ for staff to discuss the best use of communication tools.

Returning a verdict of medical misadventure, Coroner Dr Myra Cullinane endorsed the changes at the hospital and recommended the reinforcement of reliance on full clinical information rather than sole reliance on the CTG trace to monitor foetal well-being.