The angry parents of a four-day-old child who died after a catalogue of errors during his birth at Antrim Area Hospital today said they had suffered "every parent's nightmare".
Olivia Bell (30) and Paul O'Neill (35) say they think of their son Paul Samuel "every day of their life" since he died in November 2005. And today they demanded better training for midwives across Ulster.
The Antrim couple were forced to make the heartbreaking decision to switch off their son's life support machine four days after Paul, who was their first baby, was born unresponsive and with the umbilical cord round his neck.
Doctors told them he had a "zero chance of survival" and later died from Ischaemic brain injury.
But an inquest into his death revealed yesterday a number of errors carried out by the midwives who cared for Olivia during the labour.
Speaking after the findings of the inquest, the couple now say they hope their case will lead to no other family going through their pain.
"I was delighted when I found out I was pregnant," Olivia said.
"It was our first child.
"I was told I had pre-eclampsia, but the pregnancy was generally fine. I had a good doctor," she said.
Both parents said when labour was induced they had faith in the staff.
"When I went into labour we were both so excited," she said.
"You are blind going into that situation if it is your first child.
"We didn't know what was going on, decisions were being made.
"We just thought everything was normal.
"It wasn't until Paul was born after a labour of seven hours and 20 minutes that they both realised there was a problem."
Olivia added: "Paul was born and there was no response from him."
Paul senior added: "I was just standing there hoping to hear him make a sound or cry.
"He was taken away to intensive care and we stayed until he died, four days later.
"We were told in a very matter of fact way that this child is critical and after a second doctor saw him, we were just told he had a slim to zero chance of survival." Olivia continued: "It was a very hard decision, but we were clinging onto nothing.
"We could have waited, but that would have prolonged the agony.
"We were able to hold him and say goodbye. But we were just devastated."
After it emerged in the inquest that the midwives should have monitored the baby's heartbeat more effectively and called for medical assistance, the couple said they were left feeling "very angry".
Olivia said: "You are going in with a healthy enough pregnancy and you are told the child is alive right up until delivery. Then you go home without the baby.
"It is every parent's nightmare.
"I still feel angry about it. The way I look at it is I think, did somebody play God?
"Did somebody decide I don't need a doctor.
"A big lesson has to be learned here.
"The inquest seems to have boiled down to the CTG (cardiotocograph) that nobody monitored the child properly.
"But during the inquest our own consultant said had he been in contact with the midwives, he would have taken action.
"I always thought I should have had a Caesarean section."
The family are now calling for better continuous training.
Olivia added: "Midwives should be refreshed every couple of months on regards of what they are doing."
In a statement the family say changes should include:
- All midwifery staff in all hospitals are trained regularly and effectively in all screening machines used to monitor the baby's progress - especially during the stages of labour.
- Various professional bodies, including the National Institute of Clinical Excellence (NICE), look again at their procedures and protocols. And good practice guidance notes clearly set out.
- Clear guidelines are put in place and monitored regularly in relation to midwife-led deliveries, for example midwives seeking advice as soon as there are changes in an unborn baby's monitor.
- Notes should be kept of what happens during labour and the birth of a baby.