Northern Ireland's Senior Coroner, John Leckey, is to write to the Chief Medical Officer urging him to ensure that medical and nursing staff in hospital labour wards are constantly “re-educated and re-trained” in how to accurately interpret cardiotocograph (CTG) traces.
Mr Leckey announced his decision during the inquest in Londonderry yesterday into one of four babies who died shortly after they were born in the city's Altnagelvin Hospital, during a six-week period in August and September, 2006.
The coroner said a common aspect of all four deaths was the failure of labour ward staff in the hospital to recognise and |interpret CTG tracings of a pathological nature which required an immediate caesarean delivery.
The inquest into the death of baby Kyle Robert Parke, from Rossdale Park in the Waterside area of the city, was told the baby died from severe brain damage on September 11, 2006, twenty-two days after he was born.
Paediatric pathologist Dr Caroline Gannon told the inquest that baby Kyle had an infected placenta and did not have a heartbeat on delivery.
Professor William Thompson, Professor of Obstetrics and Gynaecology at Queen's University Belfast, who was commissioned by the Coroner to investigate the death of baby Kyle, said that “no definitive action was immediately taken” after the CTG tracings were discovered.
“Caesarean section delivery should have been performed. In the event, labour was allowed to continue for a further five hours until the normal delivery occurred. An earlier delivery might have improved the prognosis,” he said.
Prof Thompson said he agreed with other reports before the inquest which stated baby Kyle's chances of survival, even if the CTG tracings had been correctly interpreted, would have been remote.
Referring to the issue of the “misinterpretation of CTG traces”, the coroner said: “If that happened once it might be regarded as an unfortunate one-off situation. But where there is a few instances of a failure to interpret correctly CTG traces, it makes me sit back and ask why should that be.”
Mr Leckey said he would write to the Chief Medical Officer advising him of the need to provide constant specialist CTG training for all involved in the management of patients in hospitals throughout Northern Ireland.