The National Maternity Hospital has expressed its regret to the parents of a child who passed away four years previously and admitted to not properly identifying alterations in a foetal heart rate record. Molly Taylor-Smith took her first breath in the hospital on 13 May 2020, but lost her life six days afterwards due to hypoxic ischemic encephalopathy, a brain damage caused by the lack of oxygen or blood supply.
The Dublin District Coroner’s Court held an investigation into her demise, concluding a verdict of medical mishap. The court was informed that Molly’s mother, Joanne Taylor-Smith, was taken into Holles Street Hospital in Dublin on May 11th, by that time she was already six days past her due date.
The court was also informed that Joanne had a “relatively uneventful pregnancy” until signs of developing pre-eclampsia led to the initiation of labour on May 11th. Dr Adriana Olaru, who was a registrar doctor at that time, mentioned a dubious CTG [cardiotocography] test of the foetal heart rate at 6.40pm on May 12th, but it was considered satisfactory by 8pm.
Later the same day, at 10pm, Joanne’s temperature had risen to 38 degrees, and as per the hospital’s guidelines, a COVID-19 test was conducted. Dr Olaru was notified at 11pm that CTG was once again reviewed and deemed to be satisfactory, and a decision was made to proceed with a caesarian section. The doctors decided to wait for the COVID-19 result, which would be ready in 50 minutes considering the CTG remained satisfactory in the meantime.
Dr Olaru also mentioned that Joanne had expressed her desire for her husband Keith to be present at the birth, if feasible. However, at 11:55pm, while the Covid test was negative, the CTG demonstrated “pathological changes”. Although Dr Oraru had left the ward at 11pm, she wasn’t informed about the alteration in the CTG from “satisfactory to a pathological” in her absence. Dr Olaru admitted during the inquest that she couldn’t provide any explanation for why these changes in the CTG were not communicated to her or the rest of the medical team.
Following an emergency cesarean operation, Ms. Taylor-Smith welcomed her newborn Molly into the world at 00:17am on May 13th. Unfortunately, Molly had to be moved to the neonatal ICU immediately after birth and sadly died on May 19th.
Ms. Taylor-Smith and her spouse had been filled with anticipation to welcome their child, the gender of whom they had chosen not to determine ahead of time. The joy of discovering they had had a daughter was tempered by the challenging days that succeeded.
They now regularly visit Molly’s resting place as a way of caring for her. Ms. Taylor-Smith expressed how they reminisce about their perfectly healthy little girl every day, and muse on the bond she would have had with her sibling, had she survived.
Dr. Clare Keane, the coroner, concluded that medical misadventure led to Molly’s demise and the medical reason for her death was hypoxic ischemic encephalopathy, due to intrauterine hypoxia. Moreover, Dr. Keane admired the couple’s decision to donate Molly’s heart valves calling it an “extraordinarily noble act during such a challenging period”.