Five care failings led to baby death

Published Wednesday, 20 August 2014
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Senior Coroner John Leckey has ruled there were five failings in the care given to a mother in labour which led to her baby's death.

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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."

© UTV News
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5 Comments
lucylou in belfast wrote (37 days ago):
Louise in Whiteabbey==It may have been a case of a shortage of trained midwives generally rather than the trust not employing enough. In midwifery there are ,as in all specialties ,those who are more competent than others.
Joan in Co Down wrote (40 days ago):
You have fought the good fight on behalf of your late baby daughter who died due to substandard care by the Hospital. At last Justice is done for the parents Alistair and Tracy Hooks can now grieve and get the peace that they need. I am deeply sorry for your sad loss of baby daughter Alexis. Now in hands of the Shepherd. God Bless
Louise in Whiteabbey wrote (41 days ago):
Synpathies to the family first and foremost But it just highlights what a shambles the nhs is in that their wasnt enough money to provide midwives ti buay hospitals but the management can close maternity wards to save money . Midwives do an extremely important job and there is too much blame passed and not enough credit to the good work that is done by them.
karen in belfast wrote (41 days ago):
i will have these poor parents in my prayers. This can not keep on happening, going to hospital to give birth should be happy.Far to many bad is coming out now, when are the mistakes going to stop. heartbreaking news yet again. so sorry for your pain. x
Marie Ash in Aghyaran wrote (41 days ago):
"Substandard" said the Midwife, "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" ruled the judge. Absolutely unacceptable I would say!! Two years is also too long for to wait for this young couple to finally grieve for their daughter!!
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