Perfectly healthy baby died due to decisions made by hospital staff, inquest into death hears from Cian Hunt
Active decisions by medical staff at Mayo University Hospital in Castlebar resulted in the “death of a perfectly healthy baby to a perfectly healthy mother” who had already suffered two stillbirths, an inquest has found.
Advisors for the parents of a baby boy who died three days after complications from his birth at MUH in 2018 claimed his death was avoidable had he been delivered at 36 weeks as originally planned.
At a Dublin District Court hearing into the death of baby Cian Hunt, it was revealed that the boy’s mother had already experienced the loss of two stillborn babies in similar circumstances.
At the conclusion of legal filings at Tuesday’s inquest, Hunt family attorney Sara Antoniotti BL said the baby boy would not have died had he been delivered at 36 weeks.
Cian died in his parents’ arms at Coombe Hospital in Dublin on 6 October 2018 from complications from a lack of blood and oxygen supply to his brain and multi-organ failure resulting from a placental abruption that occurred at or around the time of his birth.
He had been transferred from MUH by Air Corps helicopter shortly after his birth three days earlier to receive specialist treatment to reduce the swelling in his brain.
David and Breda Hunt during the inquest into the death of Cian Hunt at Coroner’s Court in Dublin. Image: Gareth Chaney/Collins Photos
The inquest found that Cian’s mother, Breda Hunt of Rathnagussane, Kilmovee, Co. Mayo, was considered a high-risk patient due to the deaths of two perfectly formed babies in 2014 and 2016.
A former head of Dublin’s Rotunda Hospital, Peter McKenna, who was brought in as an independent expert, told the inquiry on Monday that there was “a real and well-anticipated risk” that Ms Hunt could have a placental recurrence in the 2016 caused her son David to be stillborn.
dr McKenna also said that doctors’ continued attempts to allow Ms Hunt to have a natural delivery were “inappropriate.”
Forensic pathologist Dr. Myra Cullinane returned a verdict of medical mishap, saying Cian’s death was a “very tragic case” and “the unintended result of intended actions in a medical setting”.
Although placental abruption was a naturally occurring condition, Dr. Cullinane that a verdict of death from natural causes would not adequately reflect how the baby died.
The coroner stressed that her judgment should not be interpreted as an accusation or criticism of anyone and should not be viewed as a finding on an issue that may relate to civil liability.
dr Cullinane said the case highlighted the importance of documented medical records due to the unavailability of a key witness, Murtada Mohamed, the consultant midwife responsible for Ms Hunt’s care.
While the coroner said she would not make any recommendations related to the specific circumstances of Cian’s death, she said she would ask the relevant authorities to consider formal fetal monitoring in the period leading up to a cesarean following a failed induction.
In her final submission, Ms Antoniotti said the circumstances of baby Cian’s death were “an unusual and rare” case.
However, she said MUH accepts that Ms Hunt’s recent pregnancy needed treatment due to her history of pregnancy.
The attorney said the only management known was early intervention by medical staff before Ms Hunt reached full term “to avoid the same thing happening a third time”.
Ms. Antoniotti noted that pregnancy required early planning and education about the risks.
However, she said Ms Hunt’s care plan was “far from clear”.
Ms Antoniotti asked the coroner to issue a verdict on a medical mishap and said staff at the MUH originally decided Ms Hunt’s baby would be delivered by caesarean section at 36 weeks.
She pointed out that an active decision was later made to change the plan and prolong the pregnancy, although this was never discussed with Ms Hunt, even during the nine days she was in hospital before labor was induced.
Another decision that resulted in the baby not being born for over a week after her 36th week resulted in the “third death of a perfectly healthy baby,” Ms Antoniotti said.
She pointed out that Ms Hunt was induced into labor for 18 hours with no progress, while there was a further six-hour delay before a cesarean was performed.
dr Mohamed did not provide an explanation for the delay, she added.
Although acknowledging that the actions of MUH’s medical staff were well intentioned, the attorney said such a consideration was irrelevant to a judgment.
MUH’s attorney Luán Ó Braonáin SC said the facts of the case mean that a verdict of death from natural causes is appropriate, or alternatively a narrative verdict.
“There was no medical intervention that resulted in Cian’s death,” said Mr. Ó Braonáin.
He said the baby died from an “acute, unforeseen event.”
Mr Ó Braonáin also criticized media reports on the inquiry for failing to indicate that expert Dr. McKenna were created “after the fact”.
He claimed the Hunt family lawyer tried to blame the hospital for Cian’s death, while media reports could give the public the impression that “something wrong” was being done at the MUH.
Mr Ó Braonáin said accepting recommendations from Dr. McKenna was not required due to changes already made by the MUH and there was a risk that if they were approved by the coroner they could send a message that there had been some sort of hospital failure.
He pointed out that the Saolta Hospital Group, which runs the MUH, has been commended for its proactive implementation of the National Maternity Strategy.
After the hearing, Ms Hunt said her family was comforted that changes had been made to the MUH following Cian’s death and she expressed hope that no other family would suffer the tragic loss of a baby in similar circumstances.
“We welcome the verdict of a medical mishap, but it will not bring our son Cian back, nor will it lessen our grief. Nothing will replace Cian or mend our broken hearts if we lose a third child,” Ms. Hunt said.
https://www.independent.ie/irish-news/courts/perfectly-healthy-baby-died-due-to-decisions-by-hospital-staff-inquest-into-death-of-cian-hunt-hears-41523731.html Perfectly healthy baby died due to decisions made by hospital staff, inquest into death hears from Cian Hunt