Hospital apologises for ‘shortcomings’ in care after warnings missed
Verdict of death by medical misadventure recorded in case of stillborn baby girl
Multiple “missed opportunities” to monitor a crucial metabolic marker - which, if addressed, may have prevented a tragic yet “rare” chain of events - resulted in the stillbirth of a baby girl at Cavan General Hospital, an inquest heard.
A verdict of ‘death by medical misadventure’ was recorded at the conclusion of the hearing before County Coroner, Dr Mary Flanagan, at Cavan Courthouse last week (April 15).
The cause of death, a Consultant Histopathologist explained, was “unascertained”, though a post-mortem revealed that an acute “hypoxic event “- a sudden, critical reduction in oxygen supply - occurred in utero, linked to severe metabolic acidosis, a life-threatening emergency that can be triggered by starvation.
Described repeatedly as a “complex and very difficult” hearing, barrister Luán ó Braonáin, representing the HSE and Cavan General Hospital, read a letter acknowledging “shortcomings” in baby Amelia Lily Curran’s mother’s care.
“I acknowledge the stress this has caused you and your family,” read the senior counsel, adding that recommendations from a post-incident review have since been fully implemented.
Baby Amelia Lily Curran’s father, James, does not remember the drive from the couple’s home in Carrigallen, Co. Leitrim, shortly after midnight on December 9, 2023, after receiving a panicked late-night phonecall from his wife Mary.
She had been taken to the local hospital by ambulance the evening before, at just over 36 weeks pregnant, complaining of “shortness of breath”.
Mr Curran told the hearing that he could still hear his wife struggling to breathe over the phone. She was “crying” and told him doctors “could not find Amelia’s heartbeat”, before hanging up.
Mary Curran had been feeling “unwell” from just over 20 weeks into her pregnancy. Already mother to three boys, Amelia was her fourth child, due the following month by Caesarean. This pregnancy, she said, felt “different”.
On November 13, she was admitted to hospital reporting the tops of her feet felt “burning” and “heavy.” Her blood pressure was high, and tests showed “3+” ketones in her urine - a warning the body is burning fat instead of glucose due to insufficient insulin.
Ms Curran told staff she could not eat properly, while drinking water triggered severe heartburn. She was referred back to her GP, the now-retired Dr Antoinette Gregan, who was represented at the inquest by EJ Watt BL, instructed by Carson McDowell Solicitors.
At a scheduled clinic appointment on Wednesday, December 6, Ms Curran again complained of shortness of breath. Ketones were again detected in her urine.
The following day, she attended the dentist with a sore mouth, sensitive tongue, and feet that were constantly “hot”. Prescribed antibiotics, Ms Curran returned home and went to bed unwell. During the night, she woke to use the bathroom and saw her baby move.
“I was happy to see her,” she said in her deposition, read by Kate Ahern BL, instructed by Laura Croke of Croke Medical Law.
James Curran noted his wife had been “sleeping a lot” in the weeks leading up to December 9.
On the morning of Friday, December 8, Ms Curran again felt unwell and was “very short of breath”. Mr Curran secured an emergency GP appointment, where Dr Gregan prescribed oral steroids and advised her to attend A&E if her condition did not improve.
After returning home and sleeping again, Ms Curran awoke feeling significantly worse. An ambulance was called, arriving at the hospital around 8:30pm.
She was seen in triage within an hour and five minutes despite being marked ‘Priority 2’ - to be seen within 15 minutes by an ED doctor. Due to Covid protocols, she was placed in isolation before awaiting clearance for the maternity unit.
“I was on fire,” said Ms Curran, who moved a chair to a window before passing out from exhaustion. She does not recall being connected to monitors or drips and was later told a doctor had come and gone. Blood tests would later reveal severe metabolic acidosis.
At one point she began screaming for help. When a nurse arrived, Ms Curran “held her hand and begged for help” as she was “really struggling to breathe”.
“I do not remember much after that, except being told that Amelia had died.”
Her next memory is waking in Intensive Care.
When Mr Curran arrived at Cavan General, he entered a room with seven or eight staff present. Mary sat upright in bed, repeating, “They can’t find a heartbeat.” As time passed, she became increasingly “distressed,” begging doctors to “make it stop” and to get Amelia out.
“I don’t know how long we were in that room, but it felt like forever,” he said.
As Ms Curran was taken to theatre, Mr Curran waited outside, believing they had “made a mistake” and that he would soon hold his daughter safely. Instead, he was brought to another room, where Amelia was eventually placed in his arms.
“They handed her to me and she looked absolutely perfect. She looked like Seán, our youngest boy, and she looked like she was just asleep. I sat staring at her, talking to her, wishing she would open her eyes. I never wished so much in my life for a child to roar and scream the place down. But that never happened. I don’t know how long I sat in that room with Amelia.”
In ICU, Mr Curran worried he might faint seeing his wife hooked up to a bank of machines.
“Mary looked very sick and was completely out of it. She didn’t know what was going on. I had been told by staff not to mention the baby to Mary.”
There were more than a dozen medical witnesses called to give evidence directly at the Cavan inquest, either in person or virtually, with the depositions of several others read onto the record.
Dr Ahmed Yassin Hazzar, a registrar gynaecologist now based in the UK, told the inquest he had not been “aware” of Ms Curran’s “3+” ketones in November when she was admitted at 32 weeks for suspected pre-eclampsia, and said he was “sorry for that”.
Appearing via video link, he was asked if that knowledge would have changed his management of Ms Curran’s case. “Definitely something should have been done with 3+ ketones,” replied Dr Hazzar.
Dr Sharmeen Saeed, medical Senior House Officer, who met Ms Curran as an outpatient on November 22, also said she was “not aware” of the ketone findings. Though she acknowledged protein in the urine had been noted.
She said had she been made aware it may have prompted a further referral if diabetes was suspected.
Dr Rukhsana Majeed, senior registrar, saw Ms Curran as an outpatient at the end of October at 29 weeks pregnant, and again on December 6. She told the inquest there were “no policy or guidelines to follow” regarding persistent ketones in non-diabetic patients, either nationally or internationally, describing the condition as “very rare”.
Dr Gregan said she was “wasn’t aware” of Ms Curran’s history of ketonuria when she examined her on December 8. She described metabolic acidosis as a “rare complication”, which she had “never come across”.
She prescribed Ms Curran with a course of oral steroids, and a referral letter should she attend A&E.
Emergency staff also outlined how Covid protocols impacted care, despite guidance that pregnant women over 20 weeks should “go straight to maternity irrespective” of symptoms.
Evidence was given by the Emergency Department registrar (Dr Atif Asghar) who attended Ms Curran; from the Medical Registrar (Dr Ayesha Naseem) who escalated Ms Curran’s case at 11:55pm after she failed to find a foetal heatbeat; and the Obstetric registrar Dr Hala Farhan, who initiated management of metabolic acidosis, and co-ordinated Ms Curran’s obstetric care.
“No one contacted me about this lady until the registrar,” noted Dr Farhan, now of Dublin’s Holles Street Hospital.
The initial medical admission, she stated, was to exclude the possibility of a pulmonary embolism, or blockage of the lungs.
Ms Curran later underwent a C-section, but baby Amelia was deceased upon delivery.
The evidence of Dr Juan Pastrana, Medical Consultant, Dr Sami Farrag, Obstetric consultant (read in), Dr Salvador Rameriez, paediatric registrar (read in), was also heard, followed by Dr Amina Javaid, Obstetric Consultant for Ms Curran.
With almost 30 years’ experience treating women with a variety of gynaecological disorders, she describe Ms Curran’s presentation as a “very rare”, and the first time she had ever encountered metabolic acidosis “without diabetes”. She said a review can “retrospectively find 1,000 things,” but could not say whether a different outcome would have occurred had Ms Curran been treated differently, with doctors unable to find “any reason” for Intrauterine demise (IUD) in around 70 per cent of deaths.
Post-mortem findings by Dr Noel McEnteggart confirmed death occurred within six hours prior to delivery. He concluded the cause remained “unascertained”, though consistent with “clinical history” of metabolic acidosis and “pregnancy-related potential insulin resistance”.
Legal submissions differed, with the family seeking a misadventure verdict, while the HSE suggested natural causes or a narrative finding.
In the end, the coroner returned a verdict of ‘Death by Medical Misadventure’ in what she said had been a “very complex and difficult” hearing.
On reflection, in his deposition Mr Curran had described the day baby Amelia died as the “worst” of his life.
“We lost a beautiful little girl and me and boys nearly lost Mary. I still wake up and think it’s all a dream until I realise Amelia isn’t here with us.”
Tragic case
Laura Croke of Croke Medical Law said it was “a very tragic case, with multiple opportunities missed”.
“Those shortcomings have thankfully been acknowledged by the hospital,” she told the Celt after the hearing had ended. “Firstly through their apology, and secondly the internal review report. That is further vindicated by the verdict received from the coroner. The family now hope the hospital will learn from this experience, and that the same outcome hopefully won’t happen again.”
Condolences
Following last week’s verdict, Cavan and Monaghan Hospital issued a statement to the Celt in which they extended their “heartfelt sympathies and condolences” to the family on the passing of Baby Amelia Curran.
It added: “We can confirm that a review was undertaken. All recommendations arising from this review have been fully implemented.
“The hospital remains available to offer any support the family may require.”
- Funded with support from the Courts Reporting Scheme