It took a month for hospital managers to learn of newborn’s death, official says

There was no risk manager at the hospital at the time of baby Mark Molloy’s death, inquiry told

Roisin and Mark Molloy were told their boy was stillborn but later found out that he had been born alive and died about 22 minutes after unsuccessful attempts to resuscitate him. Photograph: Eric Luke / The Irish Times

Roisin and Mark Molloy were told their boy was stillborn but later found out that he had been born alive and died about 22 minutes after unsuccessful attempts to resuscitate him. Photograph: Eric Luke / The Irish Times

 

A former high-ranking official at the hospital where baby Mark Molloy died has accepted it was “very odd” they only heard about the tragedy a month after the newborn’s death.

Before a Medical Council inquiry, the official who can not be named was questioned about why it took so long for managers at Midland Regional Hospital, Portlaoise, to learn about the tragedy on January 24th, 2012.

Prof Fidelma Dunne, chairwoman of the Medical Council, said it was “an adverse event of the highest level”.

Asked did they not hear anything about it in the town of Portlaoise itself, if not within the hospital, the official replied “No”.

Ms Dunne suggested it was “very odd” not to have heard anything until four weeks later.

“Yes, absolutely,” agreed the official.

There was no risk manager at the hospital – who would have taken charge of investigations into such deaths – after the previous one retired at the end of 2010, the inquiry heard.

There had been “a lot of retirements” and “the services were rationalised for want of a better word”, the official said.

The hospital had “asked for help many times” in replacing the risk manager.

The death of baby Mark was the first major incident to happen “where we were told ‘no, you can’t have this’,” the official added.

The high-ranking official was among senior staff who first interviewed the doctor in charge on the day – known only as Dr A before the fitness to practise hearing.

Asked about his demeanour when confronted four weeks later about a discrepancy in his notes of the labour, the official said he was “very contrite and very upset”.

Dr A said he became upset because he wasn’t getting any assistance from the hospital.

A midwife told the inquiry an obstetrician should have been called when monitor alarms were raised hours before baby Mark’s delivery.

A heart-rate print-out showed “question marks” – visual alerts – as early as 6.33am on the morning of the delivery.

A consultant obstetrician was not called until 8.30am.

The midwife said this was a known alarm warning the heart-rate readings of both mother Roisin Molloy and the unborn baby were similar and so action was needed to clearly identify both heart-rates.

A cardiotocograph (CTG) monitor used during the labour was known to have “limitations” which could confuse the separate heart-rates.

But staff had been instructed on what measures should be taken in such an event.

“If I was midwife looking after that woman in labour I would escalate this ... I would have called an obstetrician,” the midwife said.

The midwife also disputed evidence that a foetal scalp monitor – used to separately monitor the unborn baby’s heart-rate – was not available.

“They were there and could be used,” she said.

Dr A is facing seven allegations of professional misconduct, including that he failed to review the cardiotocograph (CTG) adequately and failed to correctly interpret it as being abnormal.

It is also alleged he retrospectively amended a CTG note from satisfactory to unsatisfactory and added the word non-reassuring, contrary to rules on medical notes.

He has rejected the majority of the allegations.

Roisin and Mark Molloy were told their boy was stillborn but later found out that he had been born alive and died about 22 minutes after unsuccessful attempts to resuscitate him.