For five years the Health Service Executive denied in face- to-face meetings and correspondence that any errors had been made in the handling of baby Caoimhe Mulcair’s case.
The coroner was not informed and no inquest was ordered immediately after her death, as is normal.
In correspondence, seen by The Irish Times, the hospital told Joan and John Mulcair the only time an inquest is requested would be if the neonatologist didn't have a cause of death.
“The possibility of something going wrong during birth isn’t reason for the coroner to be involved,” the hospital said.
The couple say they received little counselling at the hospital. Caoimhe died on a Wednesday and they didn’t get to see a counsellor, who was on holiday, until the following Monday.
The couple contacted a UK-based consultant obstetrician, Edward Shaxted, and asked him to carry out an independent report.
Ignored by staff
His report found the baby had become progressively starved of oxygen during the last hour and a half of labour. However, the signs of this on the trace of the foetal heartbeat were largely ignored by staff, according to Shaxted.
He concluded: “It is likely the baby would have survived had she been delivered earlier.”
No review of the death was carried out until this year, when Caoimhe's case was included in a wider look back by Prof Peter Boylan, former master of the National Maternity Hospital, of a number of maternity cases. His team found the foetal trace was not sufficiently abnormal to warrant earlier intervention.
“The death of the baby appears to have been completely unexpected,” the one-page report said. “Based on the documentation provided, no deficiencies were identified in the case in this case.”
The Mulcairs continued to press for an inquest into their baby’s death and the Limerick city coroner agreed to hold one this year.
The HSE made an out-of- court settlement with the Mulcairs last December with an admission of liability. It wasn’t until this week that an apology was made and later read out at the end of the inquest.
Sincere apologies
More than six years after the event, Collette Cowan, chief executive of the Limerick University hospitals group, extended her sympathy to the Mulcairs and offered "sincere apologies" for the "failings in care".
She also apologised for the “subsequent and consequent upset and distress and grief” experienced by the couple, and expressed regret for the pain and suffering caused by Caoimhe’s death.