'Medical misadventure' recorded in baby Conor's death

A unanimous verdict of 'medical misadventure' has been given in the inquest into the death of a newborn baby at Cavan General Hospital in May 2014.
Conor James Whelan, Drumora, Ballyjamesduff was delivered by emergency section on May 13, 2014. He died just 17 and a half hours later on May 14 'due to an adverse outcome'.
His death is one of five babies at the hospital since late 2012, the circumstances of which are under investigation, and the second in as many weeks in April-May 2014.
Conor's parents, Siobhan and Andrew Whelan have been present at the hearing throughout the week.
The inquest jury of three men and seven women, who it took almost 35 minutes to reach a final deliberation, also made a number of recommendations following their verdict.
An appraisal by the HSE of the obstetric and gynalogical departments of Cavan General; that a specialist in foteal medicine be assigned to the radiological department; and that 20-week scans for anomolies be recommended going forward.
'We can't let this go on,' the Chairman of the inquest jury said.
In issuing her own personal condolences to the Whelan family, Dr Mary Flanagan said that she hoped some relief had been achieved in the questions being answered, bringing to an end the 'prolonged journey' the family had gone through since first raising concerns.
General Manager of Cavan General, Evelyn Hall extended sympathies to the family and assured them that the recommendations given by the jury would be implemented.
A pathologist had earlier given the cause of baby Conor's death as that of multi organ failure due to hypoxia, in connection with ruptured vasa previa.
Perinatal pathologist Dr John Gillan, who carried out the autopsy onbaby Conor on the day on his death, stated the tearing of his blood vessels was the critical event that led to bleeding, which in turn deprived the brain of adequate oxegen supply and ultimately death.
Dr Gillin had claimed the bleeding occurred several hours before the birth, before Mrs Whelan’s membranes were artifically ruptured by a doctor at the hospital.
This  was contested by another expert Pathologist, who told the inquest it was his opinion that the bleed 'in or around' the time or Ms Whelan's admission to hospital.
 Dr Roger Malcolmson, perinatal pathologist from Leicester Royal Infirmary however accepted that spontaneous rupture of vessels at a time earlier in labour also remained a possibility.
During evidence on the final day of the inquest, a Consultant Obstetrician admitted it remains a major 'concern' for senior staff at Cavan General that a radiologist with a speciality in obstetric foetal medicine has not been appointed to the hospital, over two years after the issue was first raised.
'Yes it is a concern for us,' said Dr Azhar Syed, who also stated that the inability by the hospital to hire trained staff was also a barrier to them being able to roll-out a specialist 20-week scan, which has a far higher rate of identifying any anomolies in the womb.
Dr Syed also admitted concerns after suspicions were raised on March 21, just weeks before baby Conor's birth, on of condition of low lying placenta. When asked by a member of the jury of 10 persons, he said: 'I was not aware. No.
It was pointed out too to Dr Syed by Roger Murray of Callan Tansey solicitors, representing the family, that in a scan carried out by him that in late 2013 found the placenta to the posterior of Mrs Whelan's womb. But that following a report based on a scan taken on March 21, 2014, the placenta was found to the anterior.
Asked when he learned of the results of the March 21 scan, Dr Syed had 'no recollection', but that he would have become aware of its contents at meeting with high level management at the hospital after baby Conor's death.
Dr Syed admitted that the radiologists at Cavan General had said that they did want to continue to report on obstetric scans, outlining a feeling that their skill level was insufficent. It was subsequently agreed that Dr Syed himself would takeover in reviewing any scans the sonographers had raised concerns with.
After baby Conor's birth, it was found that Mrs Whelan has progressed through term with a undiagnoised condition of bilobed placenta, a high risk outcome of which is Vasa Previa, which is being suggested as the potential cause of the infant's tragic death.
Scanning for vasa previa is best performed earlier in pregnancy, when if the condition is diagnosed, the survival rate for the baby is 97 per cent. Without, its less than 50 per cent.
A scan of Conor’s mother Siobhan in March 2014 raised a query about a low-lying placenta, which can be a warning sign for vasa previa, but a subsequent scan by radiologists was found to be normal.
The court heard that the placenta in Mrs Whelan's womb was divided into two discs, joined by vital arteries and veins via the membrane. In baby Conor's case, a velamentous cord insertion had developed whereby the umbilical cord inserts into the fetal membranes  then travels within the membranes to the placenta.
Earlier in the week the inquest heard from Mrs Whelan who believes all pregnant women in Ireland should get 20 week scans as a may of avoid such misdiagnosises in the future.
Evidence was also given on Wednesday by Dr Ann Katherine Leahy, Consultant Paediatrician.
She informed the inquest that the regular guideline in the resusitation of babies following delivery in critical condition is to apply up to four doses of adrenaline and monitor for 10 minutes with no brain activity. In baby Conor's case, staff involved in the infant's attempted resusitation applied six does of adrenaline and that hospital staff worked for over 20 minutes before a 'heartbeat' was achieved. A later scan after baby Conor was tranferred to the Rotunda in Dublin found 'no brain activity'.
Dr Leahy said medical staff they would 'never' normally consider working for so long on a case like that again, but 'we wanted to do everything we could'.
Contrary to guidelines she admitted that she was not present for baby Conor's delivery, nor was she informed of the circumstances of his critical condition prior to her arrival and assistance in the infant's attempted resusitation after his delivery.
When asked in cross examination, Dr Leahy said she does not find this acceptable, nor does she find acceptable that it took 85 minutes before blood transfusion was administered. 'I don't find that acceptable.'
The court also heard that the rate of transfusion at Cavan General was 40mls over two hours, whereas after the infant was transferred to the Rotunda, the rate increased to 60mls over a period of half an hour.
She added that in the circumstances, a blood  transfusion should have been given 'sooner'.
Regarding Dr Leahy’s evidence, Mr Murray said the paediatrician had taken Dr Leahy up to 11 minutes to arrive in theatre after being called. She could have arrived quicker, he claimed.
She also said in cross examination by counsel for the hospital, Brian Foley BL that she did however not believe the delay in blood tranfusion caused baby Conor's death. 'I think the baby was dead at birth.'
See next week's newspaper for full report.