The parents of a baby boy who died due to abnormalities which staff at Altnagelvin hospital failed to pick up on, today said lessons must be learned from their tragedy.
The inquest was held yesterday into the death of little Kyle Robert Parke at just 22 days.
The infant from Rossdale Park in the Waterside was one of four babies to die shortly after they were born in a six-week period between August and September 2006 at the Londonderry hospital.
Northern Ireland's senior coroner, John Leckey, revealed yesterday he is to write to the Chief Medical Officer urging him to ensure that labour ward staff across Northern Ireland are constantly “re-educated and re-trained” in how to accurately interpret the results of cardiotocograph (CTG) traces.
A recent review found that the four deaths were not linked.
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 was told baby Kyle died from severe brain damage on September 11, 2006.
Kyle’s mother Shirley, speak
ing on radio, said today: “You think you go into hospital, you have a baby, you would be okay, you’re in good hands; they know what they are doing more than you would, especially your first.
“To think four babies died due to something staff lacked in training in heart readings shows obviously that they are not training staff properly.
“You would think staff in this day should be trained to spot these things.”
Mrs Parke said she was given no indication there was any problem throughout her pregnancy.
She added, however, that she she was glad Altnagelvin has since taken measures to ensure staff are trained.
A spokesman for the Western Health and Social Care Trust said today: “The findings announced are fully accepted by the Western Trust. The coroner's findings reflect the opinions and conclusions in the internal and external reviews already undertaken and commissioned by the Western Trust. The recommendations made in these reviews have been implemented fully by the trust.
“The Western Trust would like to take this opportunity to offer its condolences to the family at this time.”
Paediatric pathologist Dr Caroline Gannon said Kyle had an infected placenta and no heart beat on delivery.
“Clinically he was severely brain damaged because the brain had been deprived of oxygen. He died at 22 days of age after the ventilator was withdrawn with the consent of his parents,” she said.
“Every part of the brain we examined showed severe tissue damage. It was not just individual cells. Essentially Kyle's brain was severely damaged and a lot of the tissue had been destroyed,” she added.
Professor S Arulkumaran, head of Obstetrics and Gynaecology at St. George's Hospital in London, reported to the Inquest that the CTG tracing before Kyle was born showed “gross abnormalities” and said that based on the tracing the baby should have been delivered by caesarean within hours.
“One could argue that an earlier delivery and treatment would have resulted in a better outcome,” he said.
Professor William Thompson, Professor of Obstetrics and Gynaecology at Queen's University Belfast, 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.
“Ceasarean 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 which stated that baby Kyle's chances of survival even if the CTG tracings had been correctly interpreted were remote.
“This is the third inquest on the issue of the misinterpretation of heart traces and this is of concern,” he said.
The coroner said this was the third inquest to be dealt with one yet to take place, and with all four the issue was the “misinterpretation of CTG traces” in Altnagelvin Hospital.
“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. I am concerned about the deaths of babies in Altnagelvin Hospital, but it is a much more widespread issue,” he said.