‘We left the hospital with a box instead of our baby’

A number of recommendations have been made following a verdict of ‘Medical Misadventure’ at the inquest into the death of a Cavan baby following childbirth.

Baby Darragh McGorry died on Tuesday, March 24, 2020, at Cavan General Hospital (CGH) where he was taken for emergency treatment after being delivered following a footling breech at his home near Shercock hours earlier.

His mother Yvonne McGorry had received Antenatal Combined Care through Drogheda’s Our Lady Of Lourdes’ Midwifery Led Unit (MLU) and Kingscourt Medical practice.

The inquest, before Coroner Dr Mary Flanagan at Cavan Courthouse last week, heard “risk factors” occurred in baby Darragh’s antenatal and postnatal care “caused by medical decisions or decisions made in a medical context”.

An emotional Ms McGorry told the inquest she could see her husband Pauric standing outside the door of the theatre at Cavan General where she was rushed for emergency care in the wake of baby Darragh’s delivery.

“I could see his face,” she wept. “I knew by his face it wasn’t good. He came into me and sat beside me. He told me we would be okay, and to just remember we had each other, and we would be okay. I didn’t understand.”

Baking cupcakes

Less than 24 hours before, Monday, March 23 and four days overdue, Ms McCorry recalled a “lovely day” with her unborn baby.

“I don’t know why but I had a feeling he was coming to meet us soon. I could not get the song lyrics ‘If I had known you were coming, I’d have baked a cake’ out of my head so we spent the day baking butterfly cupcakes and enjoying our time together while my husband worked from the kitchen table.”

At 6.30pm Ms McGorry received a call from Our Lady Of Lourdes (OLOL) advising that due to Covid restrictions the MLU was operating downstairs. Ms McGorry told the midwife while she “wasn’t feeling pain” she “was feeling a downward heavy motion” she hadn’t felt before.

Ms McGorry was advised the MLU was open, and should attend if required.

She had hoped to deliver her baby using a birthing pool.

Aside from an inner ear infection, her pregnancy had gone well.

Dr Maura Milner, consultant in obstetrics/gynaecology, saw Ms McGorry at 11 weeks. She explained how OLOL’s MLU records information on “cream sheets”, which are given to the patient to bring to her next appointment, and for the combined care card to be filled out. However, the doctor accepted this doesn’t always happen.

Communication

Ms McGorry’s chart did not reference any GP notes. “It’s unusual but not unheard of,” said Dr Milner, who was asked by Sara Antoniotti SC acting for the McGorry family, instructed by solicitor Rachel Liston, if there was any policy or guidelines. “Not to my knowledge.”

In her account Dr Heather McCullagh GP saw Ms McGorry three times during her pregnancy. She did not detail her findings on the cream sheets. Instead, she uploaded details on the Socrates software system. The inquest heard this system automatically connects to hospitals in Dublin but not OLOL.

Dr McCullough said, if concerns were raised, these would be shared with a patient who in turn relays them to the hospital. “I started not to ask for [cream sheets]. Some people bring them, some people don’t.”

A 20-week anomaly scan had found Ms McGorry had a low lying placenta. But, during her final 34 week scan the placenta was “no-longer low lying”.

That same day a palpation assessment found the baby’s head down “but not engaged” in her cervix.

“I remember being happy because my GP told me the baby was breech just two weeks prior,” explained Ms McGorry, who at 37 weeks was informed by midwives the baby’s head was “[two-fifth] engaged”.

At 39 weeks midwife Fiona McKevitt found baby Darragh’s head “[four-fifth] engaged”. She was aware he was in a breech position at 32 weeks.

Confusion

By her own admission Ms McGorry told the inquest: “I thought [four fifth] engaged meant the baby was moving the correct direction. I’ve now learnt this is not the case and in fact meant my baby was less engaged.”

Dr McCullagh was asked by Ms Antoniotti SC whether the pathways of communication between hospitals and GPs for combined care would be better if standardised. “Communication is always good,” she replied.

On her due date, 40 weeks, Ms McGorry attended her GP. Her “usual” GP Dr Heather McCullagh was unavailable, and she was instead seen by Dr Deborah Ryan.

The appointment was “brief”, and Ms McGorry remembers Dr Ryan placing the Doppler ultrasound “high on my stomach near my belly button.

“This was unusual as normally the GPs and midwifes were listening lower down”.

She mentioned it to her husband Pauric, but “did not think any more about it”.

Dr Ryan denied saying to Ms McGorry two weeks after baby Darragh’s death that she wasn’t “100 per cent confident” in her abilities to say if the infant was cephalic, a position within the womb typically allowing the smoothest delivery. “No examination is 100 per cent accurate. Not that I was not use to doing the examination,” she said.

She also stated that “notes weren’t provided” to her that day.

Contractions

At 8.30pm, March 23, Ms McGorry was finishing a zoom call with friends when she got her “first contraction”.

Mr McGorry reminded his wife to stay calm. “We got my hypno-birthing strategies out. We also got the Tens machine ready and my husband ran me a bath. I began timing my contractions. They were coming every 20 minutes initially.”

By 11.30pm her contractions were “stronger, more frequent”, every 10 minutes. Her mucus plug released. “I had a little panic, but remained calm, called my husband and said it was time to call the hospital.”

Closer to midnight now, Ms McGorry put the midwife on speaker.

To her disappointment midwife Orla Keegan told her she was “not in labour”, and this was her “body’s way of getting ready to birth” as a first-time mum.

Despite concerns at living an hour away from OLOL, Ms McGorry says midwife Keegan “reassured me I was not in labour and these things take time”.

Midwife Keegan, in her evidence to the inquest, denied saying for Ms McGorry not to attend. She corrected that she would have suggested that Ms McGorry was “not in established labour”.

Midwife Keegan admitted amending a note referring to this, countersigned by colleague Rhona Byrne. The decision to do this was “my own,” she said, but done after she consulted with senior medical staff the day after baby Darragh died, March 25. “I felt it was important to note.”

Midwife Byrne’s deposition was to say she overheard the phonecall, and the advice relayed to Ms McGorry by midwife Keegan was “standard”.

She also didn’t remember seeing “any GP notes” on Ms McGorry’s file.

By 2.45am, and failing to sleep with the pain now “very strong”, Ms McGorry took another bath. After, she sat on the toilet in a back to front position and recorded her contractions. “Some were lasting over a minute, others weren’t.”

Ms McGorry remained in that position for several hours until she “could not go on” any longer. Helped up by her husband she noticed droplets of fresh blood in the bowl.

At 7.50am, almost 12 hours after contractions first started, the McGorry’s called the MLU again. Midwife Keegan answered.

“I recall giving her examples of frequency and duration,” Ms McGorry told the inquest. “The intensity had massively increased, I could no longer stand through them and needed to squat”.

She also says she told midwife Keegan about the appearance of blood.

Admission

“To our horror and disappointment, again she told us that we were not in active labour” and “if I wasn’t coping, I could come in for a check but ‘I’d be sent straight back home again’.

The McGorrys decided to attend hospital regardless.

Mr McGorry packed the car while his wife had a shower, squatting through each contraction due to the pain. She then sat on the bed, her body flushed with a “sense of calm”.

“I was exhausted at this point and thought maybe the midwife was right, maybe I wasn’t in labour. I didn’t know what to do.”

At 8.55am Ms McGorry’s waters broke. She rang the MLU from the bathroom. This time midwife Chantalle Murdock said to come to the hospital.

However, while on the toilet, Ms McGorry got “an almighty contraction, much different to the others”.

This “push contraction” felt “like involuntary impulses”.

“I had three of these contractions in quick succession. I was in horrific pain, unable to move,” she said.

Ms McGorry told the inquest she could feel something between her legs. They called the MLU for the fourth time at 9.02am. Another midwife, Fiona Maloney, answered.

“Frantic” her baby was coming and she was “stuck at home with no medical help” Ms McGorry relayed the events of the past 12 hours.

Emergency

Midwife Maloney’s “voice changed,” says Ms McGorry. She was told to hang up and ring an ambulance immediately.

At the request of the dispatcher, Mr McGorry checked between his wife’s legs.

“Then he said the words ‘It’s the baby’s foot’ and our lives changed forever,” Ms McGorry recalled.

“At this point I knew we were in danger,” she continued. “I knew my baby was in danger and my life too.”

The nearest ambulance was 35-40 minutes away. In the meantime Mr McGorry set about getting “anything he could find” preparing for the baby’s potential arrival.

“If only we’d have been so lucky to have our little baby arrive,” she reflects.

The first ambulance arrived at 9.37am, having been mobilised at 9.06am. “At this point, I thought we were okay,” says Ms McGorry. “It hadn’t crossed my mind the baby was struggling. My husband had been watching the baby’s toes and foot wriggle. This provided me with reassurances.”

Ms McGorry was moved from the ensuite to the bed and placed on her back. She says paramedic Sharon Dalton told her she’d “likely” be transferred to hospital.

“I was crying in agony by this time, so scared and couldn’t figure out how I’d survive the journey”.

Still, Ms McGorry remembers: “I trusted them.”

Soon after, advanced paramedic Robert Murphy arrived, followed by two more paramedics (9.57am).

Delivery

Mr Murphy was on duty in Monaghan, and received the call at 9.05am, arriving nearly 30 minutes later. He was the most senior medical personnel present.

“I couldn’t have driven faster,” he said when put to him by Ms Antoniotti SC that the target response time to life-threatening cases is within 15 minutes. The situation facing the McGorrys was labelled “delta, non cardiac”, second highest in terms of urgency.

Together the paramedic team “coached” Ms McGorry through delivery.

Addressing the inquest via video link, paramedic Murphy said he became aware it was a footling breech upon arrival, and he made the “clinical decision to deliver in situ”. He did this for two reasons - the difficultly in delivery in a moving ambulance, and the time already elapsed.

He did not carry out a vaginal exam, but could see a “leg presenting”.

He had never dealt with a footling breech before. None of the paramedics present had, and he was unaware that this was contraindication to vaginal delivery.

On whether he should have sought medical assistance as per the “algorithm” used for dealing with emergency situations, Mr Murphy replied: “We don’t have a local policy on that.”

He also hadn’t “training” to deal with such an occurrence.

Paramedic Murphy said it had not been relayed to him that the emergency operator had said “don’t push”.

Best intentions

Mr Murphy called the OLOL’s MLU and spoke with midwife Maloney. “At the time I was doing what I thought was best,” he said.

Midwife Maloney would meanwhile tell the inquest, had she known it was a footling breech, she would have told the paramedic not to attempt to deliver and instead bring Ms McGorry straight to hospital. She also says that “since this incident” expectant mothers are told to attend OLOL’s MLU on their due date.

First baby Darragh’s leg was stuck, then his shoulders and head. Paramedic Murphy said the umbilical cord was “not pulsating at any point" while he was there.

Baby Darragh was born at approximately 10.35am, an hour and a half after delivery first began.

“We were so relieved, it was over and he was out,” recalled Ms McGorry.

Her relief though was short lived. “I realised he wasn’t making any noise, and they didn’t put him on my chest. The room was silent. I cried out for my baby, asking was he okay?”

The response was baby Darragh “needs a little bit of help”.

“I then heard the medics counting as they performed CPR,” remembers Ms McGorry. “I was too afraid to look and see my baby in this way. My husband grabbed my hands and we began praying.”

The couple pleaded with God not to take their newborn son. “I begged my granddad who was recently deceased to please help him and let him be okay.”

Paramedic Murphy was asked would he support the provision of additional training for pre-hospital emergency staff and the introduction of localised policy. “I’d welcome any improvement on the clinical practice guidelines,” he replied.

Hope

Ms McGorry told the inquest from her lying position she heard a paramedic say “I think I have something”.

She described the moment as a “glimmer of hope”.

“We looked up. They told us Darragh was very sick and needed to go to hospital immediately.”

The time was 10:53am. During the 35-40 minutes it took to get to CGH, the “absolute shock and disbelief of what had just happened set in” for Ms McGorry.

“I thought about Darragh, what might we be faced with. My brain didn’t allow me to think he was dead.”

A member of a children’s disability team, Ms McGorry’s mind wandered to what might be if baby Darragh’s brain was starved of oxygen. “I told myself it would be okay. We would manage. Pauric and I would be able to look after him and give him what he needed.”

Ms McGorry then asked her husband to call her father to let him know she was alive. He dialled the number and “broke down”.

When the McGorrys arrived at CGH they were met by PPE-covered A&E staff.

“They wouldn’t tell me about Darragh. They kept saying the consultant will talk to me.”

Dr Ann Leahy, consultant paediatrician, delivered the news that baby Darragh had died. Ms McGorry looked to her husband “desperate for him to tell me it wasn’t true”.

Resuscitation

In their attempts to resuscitate baby Darragh was incubated. He’d been prescribed eight doses of adrenalin, along with chest compressions. His time of death was recorded at 11.34am.

Ms McGorry was asked if medical staff should bring her baby to her. “I was so scared! I didn’t know what had happened. Was he hurt? Had he visible injuries? At this point, I didn’t know his cause of death. Nothing had registered.”

Dr Leahy carried Darragh in a blue wool blanket.

“I looked away, afraid of what I might see,” recalled Ms McGorry to the inquest. “My husband took him and then something inside me told me to look. I think it was my mother instinct. I looked at him and it was instant. My beautiful baby boy.”

To this day Ms McGorry says the couple “can’t believe how lucky we were to get such a beautiful baby”.

The McGorrys thanked Cavan hospital staff for their “excellent” care. Many who worked on trying to save Darragh came to express sympathy. “It was nice to know he had touched the hearts of so many,” says his mum.

The McCorrys then spent their “only evening together as a family of three”.

Post mortem

The next morning they said “goodbye” before his body was taken for a post mortem by Consultant Perinatal Histopathologist, Dr Noel McEntagart.

He said delivery by footling breech can give rise to a number of issues - head entrapment issue, cord compression, cord prolapse, asphyxia. Any of these factors could have contributed to baby Darragh’s death.

“Acute cord compression is a possibility,” he informed. “Head entrapment is a possibility”.

His findings were that baby Darragh died of “acute hypoxic affects”. No placental pathology was conducted, and at the request of the McGorry family he recorded “early neo-natal death post vaginal breech delivery”.

Ms McGorry told the inquest she discharged herself from CGH after being checked by a consultant.

“I couldn’t be in the maternity ward without my baby. We left the hospital with a box instead of our baby. That walk was the hardest, most painful thing I’ve ever had to do. I genuinely don’t know how I managed.”

‘So beautiful’

Baby Darragh was returned to his parents the following Monday, March 30. “It didn’t matter he was dead. I had him back. I knew he was okay and safe, that’s all I needed.”

Baby Darragh was presented in his coffin. “We couldn’t hold him. We could kiss him though, and rub his cheeks. His colouring had changed. He now looked dead, but again he was still so beautiful.”

Before burial, baby Darragh’s parents placed a letter with their son. “We gave him his baby elephant from his nursery, and his daddy has the matching one beside our bed. We swapped our Féileacáin teddies and tucked the one I’d kept beside my heart all the time we were apart under his arm.”

Baby Darragh’s grandparents also sent gifts - a guardian angel and a holy necklace. His other granny gave him a letter, and his only cousin Callum gave his rabbit teddy to keep baby Darragh “safe”.

“We made sure he had his hat on and his blanket wrapped tight,” Ms McGorry told the inquest. “We said our goodbyes and carried him out of the hospital, not in his car seat like we’d planned, but in a tiny white box.”

‘Risk factors’

In asking for Dr Flanagan to return a verdict of ‘Medical Misadventure’, Ms Antoniotti for the family, said baby Darragh showed no signs of congenital defects. “But for the footling breach delivery, he would not have died.”

She impressed that a number of antenatal and postnatal “risk factors” occurred “caused by medical decisions or decisions made in a medical context in the hours and days prior to the death of baby Darragh”.

The first risk factor was an “undiagnosed breech” pregnancy, despite “regular attendances” for antenatal care.

The second was an “underestimation” of the situation Ms McGorry found herself in. “She was told she was not in labour. But we know she was suffering symptoms.”

In hindsight Ms Antoniotti says these merited Ms McGorry’s immediate admission.

Whether there was a failure to tell Ms Gorry to attend hospital, or “she was told not to come in, it was an action, a decision made, not to admit this woman”.

Ms Antoniotti stated it is “undisputed, and tragically so”, that had Ms McGorry been admitted “on the balance of probability baby Darragh would have survived”.

Even when the footling breech was diagnosed, Ms Antoniotti said “unfortunate events comprising of a number of medical decisions” were made regarding Ms McGorry’s care that meant baby Darragh was not delivered in a “safer environment”.

“Significant delays” too had occurred in the attendance of pre-hospital emergency personnel and in circumstances where “the dispatcher knew this was a footling breech”. She noted once again that a contraindication to vaginal delivery is a footling breech “because it is replete with risk”.

“It doesn’t seem the paramedics were aware of that, notwithstanding the training they’d received. They decided to breech deliver, I’m sure in the best interests as they saw it, but it was a decision that had unfortunately, probably, dire consequences.”

Ms Antoniotti highlighted again the algorithm of care recommending medical assistance. “But paramedic Murphy, he says there is no local policy. He didn’t seek medical attention. He didn’t know not to deliver.”

Verdict

The “acts” of “failure to transfer, failure to diagnose the problem, a failure to admit her to hospital when she was clearly in labour, or a decision not to admit her” Ms Antoniotti contended reflected a verdict of ‘Medical Misadventure’.

Former doctor turned barrister Simon Mills SC, instructed by Hayes Solicitors appeared for the hospital and HSE and challenged this assertion. He instead offered a ‘narrative’ verdict, warning that ‘Medical Misadventure’ is “problematic”.

His position was supported by solicitor Comyn Kelleher Tobin acting for the GPs.

But given what she’d heard over almost eight hours of evidence, across close to a dozen witness accounts, Dr Flanagan agreed the case was “best served” by a verdict of ‘Medical Misadventure’.

At these words Mr McGorry broke down. Ms McGorry, his wife, leaned over and placed her hand on his in comfort.

Dr Flanagan said the outcome “does not seek to blame anyone”. She further commented that baby Darragh’s death was the result of “an unintended act”.

Recommendations made by the family were endorsed by Dr Flanagan, who expressed her sympathy at this “terribly tragic, sad event”.

Baby Darragh’s death was recorded as ‘early neo-natal death post vaginal breech delivery’.

SUPPORT

If you are affected by issues contained in this story, please seek support. Féileacáin provides support to those affected by the death of a baby around the time of birth. Support Line: 085-2496464.