Causeway Hospital's catalogue of failures over the death of baby Alexis
Heartbroken parents whose baby girl died due to multiple failings by a hospital during her birth have said they can now "finish the grieving process".
Coroner John Leckey said there were five failures in the care given to Tracy Hook while she was in labour at the Causeway Hospital in Co Antrim which led to her baby's death.
Baby Alexis was born by emergency Caesarean section in the early hours of July 4, 2012, two weeks after her due date. Although alive at birth, she quickly developed breathing problems and died within minutes.
Speaking outside the court, Alexis' father Allistair Hook said: "It's been very, very hard but to find out that the care that was given wasn't necessarily what it should have been makes it harder.
"We have got good family support and me and Tracy are strong. It's been hard but we have come through it together.
Sitting through the three days of the inquest was difficult, said the chef, as it "brings it all back, everything that happened... but we want to bring it everyone's attention so that it doesn't happen again".
He said most people who have lost a child know how traumatic it can be, but to find out that the care Alexis received wasn't good enough "makes it a lot worse for us".
The couple revealed that on the first anniversary of Alexis' tragic death, by coincidence, Mrs Hook gave birth to a baby boy, Freddie, at the hospital where his sister had died.
The Causeway Trust has accepted the critical findings and apologised.
Senior midwife Karen Armstrong from the Coleraine hospital accepted that the care given to Mrs Hook was "substandard", claiming this was due to the unit being understaffed and extremely busy on the night Alexis died.
Mr Leckey listed five factors which caused Alexis to die from asphyxia, brought on when she inhaled meconium while still in the womb. This faecal matter can be released if the baby becomes distressed.
Mr Leckey also said there was a failure by midwives to identify the onset of labour and to give appropriate care, a lack of continuity of midwife care – the principal reason for this was the insufficient number of midwives on duty to cope with the high work load at the time.
He said there had been a misinterpretation of foetal heartbeat traces, a failure to refer escalating concerns to a consultant obstetrician and an absence of clear, unambiguous guidance over the frequency of observations of mother and foetus in the onset of labour.
He told the court – according to the evidence of expert Dr Paul Weir and "on the balance of probabilities" – that if Alexis had been delivered at 1am and not 1.42am, "resuscitation leading to survival should have been possible".
Mr Leckey added, however, that even if she had lived "it would be speculative to make any determination about the possibility of life expectancy or whether the baby would have suffered a neurological or other handicap".
Mr Leckey again expressed his "genuine and very deep sympathy" to the two devastated parents.
"This was your first baby and all the signs were good that you, Mrs Hook, would be delivered of a healthy baby. It really is a tragedy that that did not happen," said the senior coroner.
As well as asphyxia, the coroner listed as contributing factors an intrauterine infection, insufficient placenta and post maturity.
In a statement the Causeway Trust said it accepted the coroner's findings and that it had "failed to care for Mrs Hook and her baby to the necessary standard. It again offers its sincere and unreserved apologies to the Hook family".
"When this serious situation occurred the trust undertook a full investigation. Shortcomings and failings were identified and action was taken immediately to strengthen procedures," the statement added.