A midwife who did not correctly read a foetal heart monitor showing distress in a baby who later died of brain damage, made a similar error in the care of a baby who died just over a year earlier, an inquest heard.
Heather McComish, a midwife at Antrim Area Hospital, did not respond correctly to signs of foetal distress on the reading of a cardiotograph (CTG) around an hour before the birth of Matthew White at Antrim Area Hospital on November 3 2006, consultant obstetrician William Ritchie told senior coroner John Leckey.
An inquest in September into the death of Paul O'Neill, who died at four days old on November 9 2005 of brain damage, heard Mrs McComish and other midwives had not properly interpreted CTG readings.
No independent review was held into the first baby's death, nor were changes made to training of midwives in the hospital before Matthew White's death.
Mrs McComish, who has yet to give evidence in the White inquest, failed to recognise the signs of early labour in Karen White (30) after her labour was induced by Prostaglandin gel by not investigating complaints of severe pain in her back and abdomen. Dr Ritchie said he could not say the cause of brain damage was hyperstimulation of the uterus, a possible effect of Prostaglandin.
"Hyperstimulation usually happens within four hours of taking Prostaglandin, but strong labour took place outside four hours in this case," he said. "It was failure to diagnose labour [which caused death]," he said.
" Labour can affect the baby and stress the baby but the facilities were there for this."
"Once labour starts we can monitor the baby with CTG. If the CTG trace had been monitored problems with Matthew would have been identified earlier."
A report to the Northern Health and Social Services Trust by Verena Wallace, gave recommendations for the midwifery practice of Mrs McComish.
Reading the conclusions of her report yesterday, Miss Wallace said: "Mrs McComish failed to adequately assess onset of labour leading to very sad and serious consequences.
"This, however, was not a deliberate failure to provide adequate care. The trust has recourse to a disciplinary procedure but I recommend Ms McComish undergoes supported practice in the ward environment on the understanding that a midwifery supervision review is carried out."
Mr Leckey expressed shock that no objective assessment of Mrs McComishs's ability to carry out CTG readings was made after the first incident.
"It's inconceivable to me that such a glaring omission occurred."
Mr Leckey agreed with the submission of Thomas Fitzpatrick, counsel for Dr and Mrs White, that Miss Wallace's report was "incomplete" because it did not deal in detail with Mrs White's care overnight.
He said she can consider her original report and whether to withdraw the original report.