AN INQUEST into the death of a newborn baby in Altnagelvin Hospital in Derry was told yesterday that an emergency Caesarean delivery was delayed by up to 15 minutes because medical staff were unable to contact an on-call anaesthetist due to problems with her pager.
The inquest into the death of 24-day-old Ronan O'Brien from Mourne Park, Newtownstewart, Co Tyrone, was the fourth inquest into sudden neo-natal deaths in Altnagelvin Hospital in a six-week period in the summer of 2006.
Northern Ireland's senior coroner, John L Leckey, was also told that vital records of the baby's heart rate had gone missing and that despite exhaustive searches none have ever been recovered. Instead a "retrospectively written note" relating to one of the missing records was found.
Prof William Thompson of Belfast Royal Maternity Hospital, who examined the death on behalf of the coroner, said Baby Ronan, who died from severe brain damage caused by a prolapse of his umbilical cord which cut off his blood and oxygen supplies, might have been less severely brain damaged if the delay in contacting the duty anaesthetist had not occurred.
"Minutes really do count in such situations. Time is of the essence," he told the inquest.
"An umbilical cord prolapse happens in one out of every 500 cases and the survival rate is 80 per cent even though it is a very serious obstetrics situation and that 80 per cent includes babies with severe brain damage," he said.
Prof Thompson said he had never before come across a situation in which foetal heart rate records had gone missing.
"Most records are kept for 25 years. They are a very important part of the case record. They definitely make a huge difference in my ability to assess cases of this nature.
"It is very sad in this particular case they are missing. We don't know how long the baby's oxygen and blood supplies were cut off for," he said.
The surgeon who carried out the emergency Caesarean, Dr Kenneth Nathan, said he was "scrubbed and gowned" in the operating theatre but that the midwives were unable to contact the anaesthetist Dr Karen McGrath.
"I ran to the phone and contacted the switchboard. As I did so Dr McGrath arrived," he said.
Dr McGrath, who did not give evidence to the inquest, had told maternity staff that she was having problems with her pager at the time.
In a statement she said her regular pager was being repaired and she had been given a temporary one as a replacement.
Mr Leckey was told that as a result of the maternity staff's delay in contacting Dr McGrath, who now works at the Alderhay Hospital in Liverpool, the hospital authorities had installed a new emergency contact system.
Returning a verdict of death based on the medical evidence, Mr Leckey said the death of baby Ronan O'Brien raised a number of key issues.
"One, if Baby Ronan had been delivered by Caesarean section 15 minutes earlier, the outcome may have been more favourable and Baby Ronan may have survived; two, the reasons for the delay in contact being made with the duty anaesthetist; three, the missing cardiotocograph traces and the explanation for that."
Speaking after the inquest into her son's death, Alison O'Brien said it would not change what happened to her.
"It is, however, fortunate that my awful experience brought about changes in hospital policies and guidelines that I would have expected as a minimum in the care I should have received.
"I just hope that no other family would have to experience what we have gone through and hope that all staff involved in the birth of children take on board the findings of the coroner today", she said.