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Difficulties in ventilating a baby boy in the first 11 minutes after he was delivered at the Midlands Regional Hospital in Portlaoise nine years ago were not a factor in his death, an inquest has heard.
The baby, Aaron Cullen, died five days later on May 9, 2016 at the Coombe Hospital in Dublin where he had been transferred for specialist care after being born in an unresponsive state.
A fresh inquest into Aaron’s death had been directed by the Attorney General to allow new evidence to be heard that was not before the original inquest which concluded in March 2019 when a narrative verdict was recorded.
The original post-mortem attributed the cause of death as renal vein thrombosis (blood clotting in the vein that carries blood away from the kidney) due to acute and chronic lack of oxygen to several organs.
The reopening of the inquest was requested by the baby’s mother, Claire Cullen, after she obtained documents under freedom of information legislation from the MRH in Portlaoise. They indicated that a nurse had raised concerns about efforts to resuscitate Aaron in the immediate aftermath of his birth.
It heard evidence during a three-day sitting of Dublin District Coroner’s Court this week from paediatric nurse, Elaine Sheehy, who expressed concern about the low flow of oxygen being used to ventilate the baby before she arrived in the theatre 11 minutes after Aaron had been delivered by emergency caesarean section.
Ms Sheehy also claimed the mask being used to give oxygen to the baby was too big.
The inquest heard that Aaron was only successfully intubated at the third attempt 21 minutes after he was born.
However, a perinatal pathologist, Paul Downey, who was asked by the coroner to review medical records in the case, said he did not believe any issue with the delivery of oxygen at birth had caused the baby’s death.
Dr Downey said the autopsy’s findings could not be explained by a potential absence of oxygen therapy for up to 11 minutes.
He attributed the cause of death to severe and persistent pulmonary hypertension (high blood pressure in arteries in the lungs) due to blood clots in multiple organs.
Dr Downey, who was appearing as an expert witness, said Aaron also had a rare underlying mitochondrial disorder that had only been found in about 30 people worldwide. While the condition should be noted on the death certificate, he said its effect was “uncertain.”
The pathologist gave evidence that the clotting in the baby’s kidneys would have developed at least a week before the baby’s birth and was responsible for his poor condition at delivery.
Regardless of any issue with oxygen delivery, Dr Downey said Aaron was “already in extremis immediately after birth.”
In reply to questions from the coroner, Myra Cullinane, he stressed that he was not saying issues with resuscitation of the baby had no effect but he was satisfied they were not the cause of his death.
Dr Downey said he was also satisfied that the pulmonary hypertension was not caused by the baby having smaller lungs than normal.
In a closing submission, counsel for Ms Cullen, Fiona Gallagher BL, said Aaron’s death had been prolonged and exacerbated for his family by the holding of a second inquest which arose from not all information being disclosed at the original hearing.
Ms Gallagher said the entire process was “sub-optimal” including in relation to the recording of medical notes and the absence of witnesses so that Aaron’s family had to deal with information “in a vacuum.”
She claimed they were left with “unknowns” that might never be answered.
Ms Gallagher said Ms Cullen also felt strongly that she was not able to make an informed decision about her maternity care.
She outlined how an urgent referral for a fetal abnormality scan in the Coombe Hospital had been made after excessive amniotic fluid was found around the baby during a check-up on April 29, 2016 but it appeared the matter had not been followed up.
Ms Gallagher reminded the coroner that Ms Cullen, who was on her first pregnancy, had already been considered a high-risk patient by her consultant.
She said Ms Cullen would have attended the Coombe straight away herself but she believed the risk had been minimised and not brought to her attention “in an appropriate fashion.”
The barrister claimed there had also been a delay in the delivery of the baby after there had been a number of abnormal CTG readings, while efforts at ventilating Aaron after his birth were “sub-optimal.”
Ms Gallagher said Aaron’s family did not accept the evidence that issues about delivering oxygen to him played no role in his death as several medical witnesses had acknowledged that earlier intubation would have been preferable.
However, counsel for MRH at Portlaoise, Luán Ó Braonáin SC, said the appropriate verdict would be one of death due to natural causes.
Mr Ó Braonáin also informed the coroner that the implementation of a large number of recommendations arising out of a HSE review of the circumstances of baby Aaron’s death was “an ongoing process.”
Dr Cullinane recorded a narrative verdict in line with detailed, complex medical evidence heard including the cause of death determined on post-mortem.
The coroner also noted that changes in the flow of oxygen 11 minutes after delivery of baby Aaron had resulted in “some improvement” including in terms of his heart rate.
She noted and endorsed various recommendations that were being actioned by the HSE particularly in relation to documentation and training as well as communications among medical staff and with patients as such issues were “a recurrent theme” at inquests.
Dr Cullinane said she also recommended that all information relevant to a death be disclosed in full at the earliest opportunity to assist inquests.
Thanking the coroner for reopening the inquest, Ms Cullen asked her to use her influence to address the fact that there are no obligations to implement her recommendations.
Dr Cullinane replied the issue was under consideration as part of an ongoing review of the coronial process by the Department of Justice.
Commenting on the outcome of the hearing, Ms Cullen, said her “nine-year fight” had reached a conclusion that was “fair and just” for her son.
“Aaron’s human rights at every level were hindered and impacted throughout every investigative process into seeking answers towards an understanding of what actually happened to him,” she added.
The Portlaoise woman, who is co-founder of the Safer Births Ireland organisation, said the additional information about her son’s death would never have been disclosed to her if she had not sought it.
Ms Cullen said not having such information available to her family and the coroner at the original inquest had “a huge catastrophic impact on my life.”
She claimed it was unfair for any bereaved person to have information withheld about the death of a loved one.
“Today I leave the coroner’s court knowing that I did everything in my power to offer my son the dignity and respect as a human being that he deserved,” said Ms Cullen.
While she took no comfort from the additional information, Ms Cullen said she had more understanding about what had happened.
She said that caused some distress as there was a feeling that “something could have been done.”
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