Stillborn baby's parents' quest for justice has already saved lives, says coroner
Mothers should not be afraid to ask for a second opinion, baby Cara inquest is told
A Londonderry couple who pursued a landmark inquest into the death of their stillborn daughter have saved the lives of others, a coroner has said.
Michelle and Barry Rocks were praised for fighting "very hard" for their baby daughter following her death at the Causeway Hospital on June 26, 2013.
The coroner investigating the groundbreaking case said in his lengthy findings that the actions taken by the couple have prevented other families from suffering the same grief.
Coroner Joe McCrisken, in his 10-page document, said that extensive system changes have been made within the Northern Health Trust which prove lessons have been learned.
"Baby Cara should not be remembered as the baby who lost her life as a result of failures in her care, but as the baby who brought about changes in antenatal care in Northern Ireland," he said.
The coroner also accepted that Mrs Rocks repeatedly asked for a Caesarean section during antenatal appointments but was denied the procedure.
The trust previously accepted a series of failing in the Rocks' case and have since brought in a number of changes in how they deal with expectant mothers.
Coroner McCrisken went on to thank baby Cara's parents, from Moneymore, for not taking "no as an answer".
He added: "Thank you, Mr and Mrs Rocks for your fortitude, for seeing this through, not taking no for an answer and fighting very hard for your baby.
"I really believe that things have changed for the better. The actions you, and the trust, have taken have already prevented other families from going through the grief you have gone through." In his opening statement, the coroner said that baby Cara never got a chance to take a breath or open her eyes.
He was highly critical of Mrs Rocks' antenatal care when she was induced at the Coleraine hospital on June 26, 2013.
In what he described as the "golden hour" when medics found difficulty tracing the baby's heartbeat, he said that the actions of staff failed baby Cara and they did not "comprehend the seriousness of the situation".
Medics gave incorrect readings from the CTG (cardiotocograph) which they recorded as suspicious and not pathological, which the coroner said was a "crucial error". He went on to criticise Dr Ciara Daly and Dr Deidra Lim for wasting time during this crucial hour.
"She (Dr Lim) accepted she came to the wrong decision and the final seconds and minutes were lost during this time as they did not appreciate what was happening," he added.
Baby Cara was delivered by C-section at 4.33pm and despite extensive efforts to resuscitate her, she was pronounced dead 10 minutes later.
The corner also said that Mrs Rocks was adamant she wanted a C-section and expressed this view during antenatal appointments, but was denied this by Dr Rachel O'Flaherty when she was 36 weeks pregnant.
Despite Dr O'Flaherty's evidence that Mrs Rocks was still undecided about the mode of delivery, Mr McCrisken said it appeared a plan for VBAC (vaginal birth after C-section) was made during this appointment.
The coroner said: "The trust does not accept she was refused a C-section. I'm satisfied she was refused a C-section at this appointment. Mrs Rocks' opinion and her voice on the mode of delivery was not properly taken into account by Dr O'Flaherty."
A statement from the family was read out by their solicitor Lawrence McMahon, who said they have dealt with their loss with strength and dignity.
"Cara has not been forgotten and we, as her parents, have persisted in seeking the truth," they said.
"We will never forget our wee angel, Cara. We know we can't bring her back, but we welcome the verdict of the coroner and his findings. We know we have done what we had to do to get justice.
"It should always by the patient's decision regarding the mode of delivery. Mothers should not be afraid to ask for a second opinion if they have any doubt about decisions made, mothers should ensure that their wishes are correctly recorded at each appointment, mothers should be aware of the grade of doctor that they are seeing at each appointment.
"A mother's intuition and women's right to choose the mode of delivery is important and should be respected. We ask doctors and midwives to treat each patient as they would their own mother, wife, sister or daughter."