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Jury return verdict of 'medical misadventure' in death of baby

Jury return verdict of 'medical misadventure' in death of baby

A verdict of medical misadventure has been returned in the inquest of baby Conor Whelan.

The unanimous verdict was delivered in court this evening. His parents Siobhan and Andrew were visibly emotional when the verdict was announced.

The coroner extended her sympathies to the family.

The jury also made recommendations including the appointment of an obstetric radiologist at Cavan General Hospital and for all pregnant women at 20 weeks.

General manager of Cavan General Hospital Evelyn Hall also apologised to the family and said all recommendations would be supported.

Baby Conor's time of death was just seventeen and a half hours after he had been delivered by emergency caesarean.

Coroner Mary Flanagan has been hearing testimony in the inquest since Monday. This afternoon she gave a summary of evidence to the jury before offering two verdicts to the jury for their consideration; medical misadventure and a narrative verdict.

Following a summary of the evidence in the case Ms Flanagan said based on the evidence presented over three days she believed medical misadventure was the most appropriate verdict. It did not denote medical negligence she reminded them.

Both legal teams said they would accept a majority verdict in the case.

The jury returned a verdict shortly before 6pm.

Conor’s parents, Siobhan and Andrew, have been in Cavan Court all week.

Mum Siobhan presented at Cavan General Hospital on May 13. She had called ahead to say she was in labour, but when she arrived she discovered she was bleeding, causing her to cry out for help.

She was treated by midwives and doctors at the hospital and a decision was taken to manually break her waters, via an artificial rupture of the membrane (ARM).

Shortly after she was rushed to surgery and underwent an emergency caesarean.

Conor was born showing no signs of life but a heartbeat was eventually recovered and the infant was transferred to the Rotunda for emergency care. 

However, he was brought back to Cavan to spend his final hours with his family and he passed away around 7.30am on May 14.

On Monday the court heard testimony from Ms Whelan who said she “begged” staff not to break her waters and asked for a section instead.

After the birth it was established that Ms Whelan had been suffering from an undiagnosed obstetric condition known as vasa praevia. This is when foetal blood vessels cross or run near the internal orifice of the uterus. A bilobed placenta was also identified; her placenta was divided into two discs, joined by vital arteries and veins via the membrane.

Conor Whelan is one of four babies who died in Cavan General Hospital in a period of 30 months.

His death is included in an as-yet unpublished HSE review. 

Earlier, the inquest was told by an expert that it is “likely” the breaking of a woman’s waters by hospital staff could have caused a rupture which caused her baby to lose blood.

Dr Roger Malcolmson, a consultant paediatric pathologist, based in the UK was present in Cavan Court today to give evidence in the inquest into baby Conor Whelan.

Dr Malcolmson said the baby’s cause of death was damage to his organs because of blood loss, due to a rupture in the vasa praevia.

Vasa praevia is an obstetric complication in which foetal blood vessels cross or run near the internal orifice of the uterus.

Conor’s mum Siobhan had been suffering from the condition but was undiagnosed at the time of his birth.

The court heard earlier this week that Siobhan underwent an artificial rupture of the membrane (ARM) which broke her waters, shortly before she was rushed to surgery.

In his deposition, which was summarised in court today, Dr Malcolmson wrote:

“Having carefully considered the issues summarised above within the limits of my area of expertise, I consider it likely that the pathologically relevant rupture of the praevia vessel....could have occurred during the artificial rupture of membranes.”

In court he accepted the possibility of an earlier spontaneous rupture.

His deposition also states that there was “some bruising of the scalp noted, in keeping with a mild degree of trauma during labour/delivery”. 

Earlier the court heard Dr John Gillan, who carried out the postmortem on the infant, determined that it was "tricky to say" if the ARM was a contributory factor in the baby's death. 

Dr John Gillan, who carried out the autopsy on baby Conor, said the infant was deprived of an adequate supply of oxygen due to pressure on the vasa praevia which lead to rupture in the vessels,  causing the baby to lose blood.

Vasa praevia is an obstetric complication in which foetal blood vessels cross or run near the internal orifice of the uterus.

Dr Gillan told the Coroner's court today that in his opinion this bleeding could have occurred up to two hours before Ms Whelan attended hospital he said.

When asked if the manual breaking of Ms Whelan’s waters was a contributory factor in the infant’s death he said it was “tricky to say”.

“Certainly there was a torn vessel present at the site of the ARM (artificial rupture of the membrane),” he said.

The baby was alive when mum Siobhan arrived at hospital.