Medical Misadventure Verdict in Baby Mary Kate Kelly Inquest
The Health Service Executive have been told to urgently prioritise the need to learn lessons from patient fatalities at the conclusion of the recent inquest into the death of Baby Mary Kate Kelly in the Midland Regional Hospital Portlaoise last year. The family of Baby Mary Kate, Ollie Kelly and Amy Delahunt, represented by Orpen Franks Solicitors, received the verdict of medical misadventure in Limerick’s Coroners Court on December the 10th 2014.
Ms. Delahunt, in the final stretches of her pregnancy, presented to Portlaoise Hospital on the 21st of May 2013 concerned about a reduction in her baby’s foetal movements. A CTG was commenced in order to monitor Baby Mary Kate’s heartbeat, and despite noted repeated decelerations and the absence of any accelerations, she was informed that she could be discharged from Portlaoise Hospital and attend a previously arranged appointment at St. Munchin’s Hospital in Limerick the following day. On Wednesday, the 22nd of May, she attended St. Munchin’s Hospital at which the parents were told that no heartbeat could be found and that Baby Mary Kate had tragically died.
Having subsequently been reassured by representatives of Portlaoise Hospital that no such mistake had been made before nor would happen again, it was only after watching a PrimeTime Invesitages programmes in January of this year that Ollie and Amy became aware of four previous baby deaths in similar circumstances in Portlaoise Hospital in the recent past. All five baby deaths had a number of themes in common with one another, including the misinterpretation of CTG traces and a failure to escalate matters to consultant level.
The jury at the inquest, in addition to a verdict of medical misadventure, delivered a set of eleven recommendations for the HSE to adopt going forward, specifically;
1. All staff should receive adequate and ongoing training on the interpretation of CTG traces.
2. The HSE should promote and support a culture of lifelong learning for healthcare professionals.
3. Midwives and doctors should have clear written instructions and training on escalation of care to consultant level.
4. Patients should not be discharged from hospital in a case of a non-reassuring CTG or concerns regarding foetal movement without the consultant being consulted.
5. Patients discharged to monitor fetal movements should be given clear written instructions.
6. The HSE National Open Disclosure Policy should be implemented in full.
7. The HSE should urgently prioritise the need to learn and apply the lessons from fatalities.
8. The HSE should publish and be obliged to adhere to guidelines on adequate staffing levels in Maternity hospitals.
9. The HSE should ensure that systems are in place in order that a senior consultant and a senior nurse/midwife take responsibility for dealing with serious adverse events when they occur.
10. Training should be provided by the HSE for senior clinical staff in dealing appropriately with patients in the context of serious adverse events.
11. In the event of a sensitive situation arising such as the loss of a child, the parents should be met for any follow up discussions at an external venue outside the hospital to avoid any further distress.
Amy Delahunt and her solicitor, Rachael Liston of Orpen Franks Solicitors, spoke to Will Faulkner on the Midlands Today Show on the 11th of December:
For more information please contact Rachael Liston on:
Tel.:+353 1 637 6200