Eight-year wait for details of why son died
The White family waited almost eight years to find out details of the events that resulted in the death of their baby boy.
Matthew White was five days old when he died from brain damage in Antrim Area Hospital in 2006.
A neo-natal team rushed to resuscitate the infant after he was born – hours after his labour was induced.
It is the second such inquest within the past three weeks which indicated errors in care within the Northern Health Trust.
In August, 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.
On November 3, 2006, Mrs White's labour began sometime between 11pm and 1.30am.
Medical experts agreed that with correct intervention the baby could still be alive and a healthy child.
The baby's heart reading in a cardiotocograph (CTG) had given no cause for concern when it was first taken around 6pm the evening before.
It was agreed that Mrs White was having Braxton Hicks – contractions without pain – around 9.22pm that evening but that a subsequent CTG reading at 11.10pm did show signs that the baby was in distress while the mother complained of having severe cramps and back pain. Midwifery staff incorrectly diagnosed Mrs White's complaints of increasing pain as "gel pains" during the morning.
Instead, the midwifery staff ought to have responded to Mrs White's complaints by assessing uterine contractions to the fetal heart, and following that, if necessary, conducted a vaginal examination.
Where appropriate, analgesia ought to have been offered.
Mrs White should have been assessed four-hourly but this was not done and she should have been reassessed by 2am.
Midwifery staff at the hospital failed to recognise the onset of labour and to take appropriate action by summoning medical staff.
When it was discovered that labour had commenced, Mrs White should have been transferred to the labour ward at an earlier stage for assessment and for monitoring of the fetal heart.
From the time between 6.12am and 6.25am there was a failure to recognise the CTG trace as indicating fetal distress.
A subsequent delay in starting the appropriate obstetric care happened when there was failure to contact the registrar or consultant at the appropriate time.
The trust found that Mrs White was not assessed appropriately between 11pm and 6am.
Despite complaints from Mrs White, midwifery staff failed to respond adequately.