Boy died from brain damage after delays in delivery, inquest told

A three-day-old boy died from brain damage caused by oxygen deprivation following delays in his delivery at Kerry General Hospital, an inquest has heard.

Milo Scanlon, of Cleandries, Causeway, Co Kerry, died on March 30th, 2015, after being transferred to Cork University Maternity Hospital. He was born in the Kerry hospital's maternity unit following an emergency Caesarean section, which followed earlier failed delivery attempts.

Milo's mother, Sinead Scanlon, told the inquest she and her partner, Mike Mangan, went to Kerry General Hospital on March 25th, 2015. Consultant obstetrician Dr Mary McCaffrey broke her waters the next day and she went into protracted labour.

Ms Scanlon recalled a nurse saying at about 9pm that she might need a Caesarean after signs of foetal distress were noted.

The obstetrics registrar on call, Dr Nor Ariah Mat Nor, arrived at 10pm by which time Milo’s heartbeat had settled down. She again examined Ms Scanlon at 11.23pm and it was decided that active pushing should start an hour later as she was fully dilated.

Heartbeat

After Ms Scanlon began pushing at 12.20am it was noted that Milo’s heartbeat had increased to 180 beats per minute. Dr Nor arrived at 12.40am and decided to perform an instrumental delivery using a Kiwi vacuum cup, which failed to attach to Milo’s head.

Two further instrumental delivery attempts, using a Neville Barnes forceps, also failed. When Milo's heartbeat fell to 80 beats per minute, Ms Scanlon was moved to the operating theatre.

The inquest heard Dr McCaffrey, who was on call, was contatced and instructed Dr Nor to stop everything as she was on her way. The inquest heard she was not informed about the earlier delivery attempts.

Ms Scanlon and Mr Mangan both recalled panic in the labour ward and it taking a long time for her to be brought to the operating theatre, which staff denied. Mr Mangan said there was eventually a rush to the operating theatre but it was in darkness and staff had not yet arrived.

The inquest heard conflicting evidence of the times when various staff arrived in the theatre. Dr McCaffrey began preparing for the Caesarean but had to wait for an anaesthetist to top-up Ms Scanlan’s epidural. The Caesarean began at 1.15am when Ms Scanlon was still conscious. She recalled feeling the incision but said the anaesthetic took effect a minute later.

Unresponsive

The inquest heard Milo was unresponsive and flat when delivered at 1.17am and paediatric staff tried to resuscitate him. He was transferred to the Cork hospital that morning and later died there after being taken off a ventilator.

A postmortem revealed Milo died from global hypoxic ischemic encephalopathy, where he suffered brain damage due to oxygen deprivation during birth.

Jerry Healy SC, for Ms Scanlon, said there was confusion over the exact times but the outcome boiled down to a 23-minute delay in carrying out the emergency Caesarean, which had calamitous consequences for Milo. “The child might well have survived had he been delivered in time – that is, within 10 minutes.”

Lorraine Scully BL, for Kerry General Hospital, said it was not known why Milo's heartbeat had begun to drop after the attempted deliveries and while there were systems errors, everyone in the maternity unit had done their best.

Ms Scully apologised on behalf of the hospital.

The jury, which delivered a narrative verdict, recommended that all information be clearly communicated between medical staff at all times and all clocks and pagers be synchronised to show the correct time after hearing of discrepancies of six to eight minutes between them.

Coroner Philip Comyn thanked the jury and extended his sympathies to Milo's parents on their tragic loss.