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Verdict of misadventure in home-birth death inquest


1109 inquest-update pic lanscape
INQUEST Sarah Williams and Emmet Heneghan at Castlebar Coronors' Court, where the inquest into the death of their son took place. Pic: Keith Henghan/Phocus

Verdict of misadventure in home-birth death inquest

‘Perfectly healthy’ baby suffocated in the womb

Neill O’Neill

The Coroner for South Mayo has returned a verdict of death by misadventure in the case of a baby boy who was still born at Mayo General Hospital in 2011, following complications at a home birth.
Over two days of evidence the inquest heard conflicting reports form the parents of the deceased infant, Sarah Williams and Emmet Heneghan, who were then living in Louisburgh, and the self-employed community mid-wife, Christina Engel from Abbey Street, Ballinrobe, as to what had happened on the night of May 23, 2011, and early the following morning, in Ms Williams’s home in Louisburgh.

Midwife’s role examined
Barrister for the parents, John Jordan BL, had sought a verdict of death by medical misadventure, stating that the call to transfer Ms Williams to Mayo General Hospital should have been made earlier than 2.15am, at which time the midwife could no longer detect the child’s heartbeat. There had been no progress in the labour since 8pm that evening, he said, describing Ms Engel as being ‘blissfully oblivious to the fact that dealing with a transfer to the hospital in an emergency would take the best part of an hour’. He said there were other ‘red flags’ in the case also.
An expert witness from the UK, retired consultant obstetrician Mr Robert Clements, explained his view that the child was in a recognised foetal position (Occipito Posterior position) in the womb with his head tilted backwards, which should have been deemed a complication of the labour. He said the midwife was aware of this and questioned the wisdom of keeping Ms Williams at home after an hour of no progress in stage two of her labour.
However, Senior Counsel for the HSE, Mayo General Hospital and Christina Engel, Declan Buckley, argued that to reach a verdict of medical misadventure there had to be a ‘clear mistake on the part of the midwife that was causative of the death.’ He contended that guidelines were followed and that there was a sudden loss in heart rate of the child around 2am on May 24, at which point the midwife declared an emergency transfer to the hospital. The expert witnesses had argued it was more likely that signs that the baby was in distress were being missed, and added that in a hospital environment the child would have been ‘immediately delivered with a forceps’ at that stage.
The inquest heard that the baby, named Kai David, was stillborn with his umbilical cord wrapped loosely around his neck. The expert witnesses described this as being in a ‘vulnerable position’. He added that the cord likely became compressed during contractions which over time contributed to the distress of the baby and the sudden loss of a heart beat. He suggested that monitoring the heartbeat during contractions rather than between them might have identified this.
The pathologist declared the cause of death as being from suffocation in the womb, and added that the child that was delivered shortly after 3.20am that morning was ‘perfectly healthy’.
Coroner for South Mayo, John O’Dwyer, said that it was neither an accident or a natural death but that it was not sufficient to say that had Ms Williams been moved earlier the child would have survived, as Kai was stillborn and there was no time of death given.
He stated that Ms Engel had done nothing intentionally wrong and recommended that midwives be given assistance at all home births by at least one other person, as the job carries an ‘inordinate burden and responsibility’. Suggesting that the ambulance service be notified of all planned home births, he recommended that distance from the hospital also be considered as a factor in deciding who is approved for a home birth.

Transfer to hospital
On Monday, the inquest heard that by the time the decision was made to transfer Ms Williams to hospital her baby’s heart beat had gone rapidly from being normal to being non-existent and a decision was made not to call an ambulance as it would take too long to reach Louisburgh and return to Castlebar – a distance of almost 50 miles. There was no emergency plan in place for the home-birth, and the midwife’s car would not start. Ms Williams was transferred to Mayo General Hospital by Mr Heneghan, kneeling on the passenger seat of his van.
Ms Williams told the inquest that a doctor told her after Kai was stillborn that had they left for the hospital earlier, her son would be alive. Christina Engel, who had been in charge of the birth, said that she called the hospital to declare an emergency transfer as soon as she noticed the foetal heartbeat decelerating. She said she has delivered thousands of babies in her career and it is ‘inconceivable she would ever continue with a home delivery where foetal distress was showing’.
There was inconsistencies in the statements of Ms Engel, Ms Williams and Mr Emmet Heneghan who described the scenes from that night as ‘farcical’. Both he and Ms Engel gave contradicting evidence over who made the decision to go to hospital, about the regularity with which the baby’s heart beat was being monitored in the crucial final hours and over who tried to start Ms Engel’s car. Mr Heneghan said that he could see his partner was struggling with the childbirth and that by the time he decided he had witnessed enough, that he ‘was more or less sure the child was gone’ and his concern was for Sarah.
“They put him on my chest for a second or two before they cut the cord,” Ms Williams said in evidence.
After baby Kai was delivered, doctors attempted to resuscitate him for 29 minutes, after which Ms Williams, according to her statement, said: “Let him go, and take me with him.”
She added: “They took Emmet out of the room and told him Kai was dead. They then came back and told me. They told me it wasn’t my fault and that I was not to blame myself and that sometimes these things happen in the hospital, too.”
Extending sympathy, John O’Dwyer said that the death was clearly a tragedy for the Kai’s parents – Sarah Williams and Emmet Heneghan – and for the midwife Christina Engel.