'Medical Misadventure' verdict at Cavan baby inquest
Knockbride East family says mum's concerns were not listened to
A number of recommendations followed a verdict of medical misadventure at an inquest into the death of a baby girl at Our Lady of Lourdes Hospital, Drogheda, three years ago.
The Louth hospital, which operates the largest maternity unit in the North East region, admitted there had been “deficits in care” after baby Willow Clarke was delivered stillborn following Caesarean section on August 15, 2018.
“The moment I heard them say 'I’m sorry there is no heartbeat’, my whole world as I knew it completely fell apart,” said heartbroken mum Pamela Clarke.
She added: “I will never get over the shock of that moment.”
Mrs Clarke, from Knockbride East near Bailieborough was admitted to Our Lady of Lourdes Hospital on the morning of August 14, 2018.
She was considered “high risk” after developing gestational diabetes during pregnancy, and coupled with having a high body mass index, was referred from Cavan General.
But the inquest heard of confusion around how guidelines in relation to monitoring the baby's heartbeat were adhered. The maternity unit was also short-staffed on the night in question yesterday's hearing (Tuesday, September 28), before Coroner Ronan Maguire at Drogheda Courthouse, was told.
Mrs Clarke, a mum-of-three,had informed doctors her last birth, nine years previous, was “extremely traumatic”. As a result, she was anxious Willow would be delivered by Caesarean.
Despite her pleadings, at various consultancy stages throughout gestation, Mrs Clarke was given a hormone pessary with the medical intention of a normal vaginal delivery upon her arrival at Drogheda.
However, in the early hours of August 15, Mrs Clarke was quickly moved to theatre after medical staff failed to locate a foetal heartbeat.
In vivid detail Mrs Clarke spoke of the panic and fear she felt.
“I kept shouting over and over 'why aren’t you putting me to sleep? Why aren’t you getting her out? What’s taking so long, why are you wasting time?'. Then they switched off the machine, the doctor with the mask walked away and someone put their hand on me and said 'it wouldn’t be right' to section me. 'Sorry, there is no heartbeat'."
She remembered: “I was confused in total disbelief and shock. They are wrong 'please just take her out' I shouted. I couldn’t understand how a perfect, healthy baby could just die. It didn’t make sense, especially when we were in the safest place possible. I wouldn’t believe it, I thought they have made a mistake and it would be okay.”
Mrs Clarke spent the night, before Willow was eventually delivered the following afternoon, listening to the cries of newborn babies. “It was extremely distressing and traumatic.”
She claimed too that, when her bereaved parents arrived, her father Vincent sought answers, only to be allegedly told: “Pamela is in a bit of a state in there, but she's young. She’ll get over it.”
Now, aged 39, Mrs Clarke says she feels the chances of her having another baby have been “stolen” from her.
She and husband Pat have been trying, unsuccessfully, for another pregnancy since early 2019.
Diagnosed with 'Unexplained Secondary Infertility', Mrs Clarke outlined in an emotional deposition: “If I cannot conceive again, I really don’t know what will happen to me. I still can’t be around expectant mothers or babies. I’m avoiding people and life situations. It’s ruining mine and my family’s life. I suffer with panic attacks, I feel angry, jealous and heartbroken. This is not me and I don’t want to have to live the rest of my life this way. My heart hurts, I still have so much love to give.”
She concluded: “How could a normal pregnancy end with me having to say goodnight to my daughter in a cold, dark graveyard instead of her warm, cosy cot?”
Earlier Mrs Clarke claimed consultant obstetrician, Dr Vineta Ciprike, hospital lead in dealing with gestational diabetes, told her and husband Pat that hospital protocol had not been followed in respect of the monitoring Willow's foetal heartbeat. She could not remember saying this, though she accepted, when questioned by solicitor Roger Murray, acting on behalf of the Clarkes, the risk of stillbirth is between four to seven times higher in cases of women with gestational diabetes.
Dr Ciprike explained that Caesareans are “complicated” for patients with diabetes as there is a risk of organ injury, and that sections are considered only for an “obstetric reasons”.
“Gestational diabetes is not an obstetric reason,” said Dr Ciprike.
Pathologist, Dr Emma Doyle, informed the inquest that baby Willow died due to an acute hypoxic episode. The exact cause of death remains “unexplained”.
Miriam Kelly, quality and safety manager at Our Lady of Lourdes, confirmed to the inquest that, in the aftermath of baby Willow's death, four changes have been introduced at Our Lady of Lourdes including guidelines on foetal monitoring for patients with gestational diabetes.
Having heard the evidence, including from three midwives involved in Mrs Clarke's care, the coroner Mr Maguire stated it was “clear” that guidelines at the Drogheda hospital regarding care of a pregnant woman with gestational diabetes were “ambiguous and confusing”.
They had not been adhered to by staff in relation to the care of Ms Clarke and baby Willow, and he added there were no warnings either about the risk associated with the use of a propess as part of the induction process.
He went on to state, based on evidence that the maternity ward was operating at capacity with 22 patients admitted and only two midwives on duty, that the unit had been “understaffed and overworked”.
Mr Maguire welcomed the changes implemented by the hospital and urged that, those not yet completed, be done so without haste.
In a statement from hospital GM Fiona Brady, read by counsel Rebecca Graydon BL after the inquest had ended, Our Lady of Lourdes recognised the “devastating” and profound impact the death and loss of baby Willow has had on the Clarke family.
“On behalf of the hospital, I would like to apologise sincerely for the deficits in care.”
Outside, Mrs Clarke welcomed the verdict, telling assembled media it has been a “long, painful three years” to get to that point.
“Sometimes I did not think I would make it.
“We stand here today after we fought endlessly for answers about the wrongful death of our little girl Willow. Healthy babies don't just die.
“Since Willow tragically passed I have always maintained this shouldn't have happened. We feel we we're listened to by the people who were taking care of me and my baby.
“Willow was silenced, but not today. My beautiful girl, your voice was heard.”
The Clarkes say their message for other families in similar circumstances, is for them to make their voice heard. “Professionals need to listen. We are human beings and not just medical numbers. Never feel stupid for voicing your concerns because it might just save your life or your baby's life. I was in the safest place possible and my voice was not listened to. We as patients are not being listened to and this must change in all aspects of healthcare.”
Continuing, she added that particular emphasis must be put on training within the country's hospitals. Mrs Clarke said she and her family have “finally” got some answers, but that their pain “doesn't stop now”.
“Please don't let Willow's death be in vain. I hope Willow's legacy will help save others, and no family must endure this terrible nightmare.”
Mr Murray concluded by saying that recommendations are “only as good as their implementation”. He said: “Pamela and Patrick and their extended family deserve enormous credit for the courage they have shown.”
The coroner said he was most impressed by the evidence Pamela and Patrick gave. “So we hope their courage in highlighting these issues will cause patient safety to be improved.”