More than three years after it was completed, the Health Service Executive has provided a couple who lost two babies at Portiuncula Hospital in Ballinasloe with a report into their second daughter's death.
The incident review report into the delivery of Amber Reilly, who died a week after being born in the hospital in February 2010, identifies serious failings in the management of her mother Lorraine's labour.
Some of these issues have resurfaced in subsequent incidents at the hospital which are to be the subject of a forthcoming inquiry.
The report says a medical registrar and a clinical midwife manager failed to accurately interpret the CTG readings of Amber’s heartbeat during labour.
It says the registrar ignored an instruction from a consultant obstetrician to divert Ms Reilly to theatre so a Caesarean section could be carried out.
Dublin City Coroner Dr Brian Farrell asked the hospital to review Ms Reilly's labour after an inquest in June 2011, and the resulting report was completed in October that year.
However, it was only when Ms Reilly and her husband Warren met HSE staff this week that it was provided to them.
High-risk
The report says Ms Reilly was “high-risk” as she had a previous stillbirth at 30 weeks and had a previous Caesarean section. Despite this, midwives did not inform the obstetrician of her arrival or the progress of her labour.
The medical notes record that Ms Reilly became “very distressed” on the evening of her admission and a clinical midwife manager queried whether she should be delivered by Caesarean instead.
However, the registrar was confident “there is no obs problem” and her epidural was topped up.
The report says that as the labour progressed, “there was a failure to interpret accurately the CTG readings on the part of the Obs/Gyn registrar and the clinical midwife manager”.
The midwife manager, who had become increasingly uneasy with the decisions made and treatments ordered, rang the consultant on-call directly. He ordered that Ms Reilly be transferred to theatre for a Caesarean.
The notes state: “OBG registrar 1 continued with the original plan for a vaginal birth after Caesarean section and to incorrectly interpret the CTG; he did not follow CMM advice or discuss options for mother’s treatment and care, or contact the on-call OBG consultant for advice.”
The first operating theatre was already in use so a second one had to be opened, and this happened without delay. Despite the consultant’s instructions, the registrar “chose to continue with his impression of the progression of mother’s labour” by providing care in the labour ward.
As a result, the consultant had to divert from the theatre to the labour ward on his arrival in the hospital.
Treatment
Ms Reilly was transferred to theatre and Amber was delivered “flat” with the umbilical cord wrapped around her neck. She was resuscitated and transferred to the National Maternity Hospital, Holles Street, Dublin for treatment.
“Baby died peacefully in her parents’ arms on the sixth day of her life, confirmation having been made that she had severe irreversible brain injury”.
After the death, the registrar continued to maintain his interpretation of the CTG and the progression of Ms Reilly’s labour was correct.
He continued to work under supervision for the remainder of his contract of employment in the hospital.
The report says the risks of a “similar untoward event” occurring have been reduced as a result of “corrective actions”, including the supervision of the registrar and further training for staff.
This was before issues emerged last month in relation to seven births at the hospital in 2014.
