A NUMBER of recommendations have been made as an inquest recorded a verdict of medical misadventure in the death of a newborn baby.
Coroner Eugene O'Connor expressed his "admiration" for Roisin (40) and Mark Molly (42) for the manner in which they conducted themselves during the three-day inquest into the death of their baby Mark at the Midland Regional Hospital in Portlaoise.
Mark was pronounced dead 22 minutes after his birth by emergency Caesarean section at the hospital on January 24, 2012.
His category of death, although initially recorded as stillborn, was changed to newborn infant after queries were made.
The jury made six recommendations in relation to activities at maternity hospitals. The recommendations were restricted to potentially life-saving measures.
Speaking after the verdict, Mr Molloy said the jury's decision "really validates two years of myself and Roisin, as it were, battling with the HSE to get answers into essentially why Mark died".
He described having to bring his baby for an autopsy in a taxi as "a particularly distressing thing to have to do", but noting recent media attention, said, "generally, through public pressure, these things do go away and I hope it does".
"What we were trying to do was not just to get answers, it was to make sure that there was lessons learned from Mark's death," said Mrs Molloy.
She was pleased "that it wasn't for nothing, that it will save other babies and other families and other babies being damaged in labour as well".
Solicitor Rachael Liston, of Augustus Cullen Law Solicitors, was critical of the length of time it took to hold the inquest.
Mrs Molloy, a Co Offaly mother of four, was in labour when she attended at the hospital just before 5am on January 24.
The coroner told the jurors that baby Mark had died as a result of anoxia (oxygen deprivation) and "this baby was in trouble from 6.30 onwards".
He cited a sequence of "unfortunate" events which appeared to indicate "a lack of action was the cause of the anoxia".
Consultant obstetrician Dr Miriam Doyle earlier told the inquest that on reviewing CTG readings (monitoring of contractions and the babies heartbeat), she believed a decision should have been made to deliver the baby some time around 7am.
Mrs Molloy had been in the care of midwives until the registrar obstetrician arrived at 7.55am.
He prescribed the drug Syntocinon (used to progress labour) and examined Mrs Molloy before calling Dr Doyle at 8.31am.
Given the CTG readings, Dr Doyle felt Syntocinon should not have been administered. She arrived at 8.39am, stopped the Syntocinon and decided to move Mrs Molloy to the operating theatre.
However, baby Mark's heartbeat was only detectable for the first minute of birth.
Thanking the jury on behalf of the Molloys, barrister David Holland said the verdict "has to some small degree lightened a terrible burden they must carry throughout their lives".
Mr Holland said the Molloys had wanted to find out what happened to their son but also "to ensure that it doesn't happen to any other baby".
The recommendations are:
* The provision of equipment for foetal blood sample testing to be made available in all hospitals where CTG monitors are used for foetal monitoring.
* Provision of clear instructions in writing as to when midwives should call doctors.
* All staff, medical and midwifery, should have adequate training in the use of CTGs.
* All staff be given clear instructions as to when Syntocinon isn't to be used having regard to the CTG trace.
* That all clocks in maternity units should be kept in correct time and synchronised.
Finally, it was recommended that all medical records should be kept contemporaneously.