Published Wednesday, 20 August 2014
Having heard a senior midwife from the Causeway Hospital in Coleraine accept that the care given to Mrs Tracy Hook was "substandard," Mr Leckey said there were five factors which caused her baby daughter Alexis to die from asphyxia, brought on when she inhaled meconium while in the womb.
After three days of evidence at the Belfast inquest, Mr Leckey ruled that there had been a failure by midwives to identify the onset of labour and to give appropriate care.
He said there was a lack of continuity of midwife care and that the principal reason for this was the insufficient number of midwives on duty to cope with the work load which was high at the time.
He added that there was also a misinterpretation of foetal heartbeat traces; a failure to escalate concerns to a consultant obstetrician; and an absence of clear, unambiguous guidance as to the frequency of observations of mother and foetus in the onset of labour.
Coroner Leckey told the court that if Alexis had been delivered at 1am and not 1.42am, according to the evidence of leading expert Dr Paul Weir and "on the balance of probabilities, resuscitation leading to survival should have been possible."
Turning to Alexis' parents Tracy and Allistair, Coroner Leckey again expressed his "genuine and very deep sympathy."
"This was your first baby and all the signs were good that you Mrs Hook would be delivered of a healthy baby, it really is a tragedy that that did not happen," said the senior coroner.
Outside the court, Mr Hook said the last two years since his daughter's death had been hard and that it was only now that the inquest was over that the couple could "finish the grieving process."
He said: "It's been very, very hard but to find out that the care that was given wasn't necessarily what it should have been makes it harder. We have got good family support and me and Tracy are strong. It's been hard but we have come through it together."
The couple revealed that on the first anniversary of Alexis's tragic death, by coincidence, Mrs Hook gave birth to a baby boy, Freddie, at the hospital where his sister sadly passed away. The little boy was delivered by the same doctor.
"Dr [Lorraine] Johnston is brilliant and we actually asked to go under her care this time around," said Mr Hook, adding that he believed Dr Johnston saved his wife's life the night his daughter died by acting so quickly once a decision was made to perform an emergency C section.
Coroner Leckey had earlier on Wednesday heard that baby Alexis was showing signs of distress in her mother's womb almost 12 hours before she was eventually born at 1.42am.
Leading expert Dr Paul Weir said a trace on Alexis' heartbeat at 2pm showed four decelerations, indicating that "the infant was showing evidence of a precarious balance of its oxygen requirement" and that as such, Mrs Hook should have been monitored more closely, even just to check if it was "an isolated phenomenon."
Following the Coroner's findings, the Causeway Trust issued a statement accepting the findings.
"The Trust accepts the findings of the inquest and that they failed to care for Mrs Hook and her baby to the necessary standard," the statement said.
"It again offers its sincere and unreserved apologies to the Hook family.
"When this serious situation occurred the Trust undertook a full investigation. Shortcomings and failings were identified and action was taken immediately to strengthen procedures. Learning from this case has been shared with maternity units in other Trust's in Northern Ireland."
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