A "PERFECTLY healthy" baby boy died after being suffocated in the womb following complications that arose during a home birth.
A verdict of death by misadventure was recorded in the death of Kai David Williams Heneghan, who was delivered in hospital after the midwife could no longer find his heartbeat.
The coroner amade a recommendation that midwives be given assistance at all home births by at least one other person, as the job carries an "inordinate burden and responsibility".
The baby's parents, Sarah Williams and Emmet Heneghan, had given evidence the previous day. Mr Heneghan described the scenes from that night in their home in Louisburgh, Co Mayo, in May 2011 as "farcical" as the baby's heartbeat began to fade.
He had suggested that they go to the hospital, but the midwife's car would not start so they had to travel in his.
Ms Williams also gave evidence that a doctor had told her that if they had left for the hospital earlier, her son would be alive.
Self-employed midwife Christina Engel, of Ballinrobe, Co Mayo, said she called the hospital to declare an emergency transfer as soon as she noticed the foetal heartbeat decelerating.
Delivering the verdict yesterday, Mayo County Coroner John O'Dwyer said it was neither an accident nor a natural death, but that it was not sufficient to say that if Ms Williams had 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.
However, he made a recommendation 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.
The medical cause of baby Kai's death, as outlined to the inquest by consultant pathologist Dr Fadel Bennani, was stillbirth due to acute intrauterine asphyxia during labour. He described Kai as being "perfectly healthy".
Earlier yesterday, an expert witness from the UK, retired consultant obstetrician Robert Clements, said 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.
Baby Kai was stillborn with his umbilical cord wrapped loosely around his neck.
Mr Clements said the cord likely became compressed during contractions which over time contributed to the distress of the baby and the sudden loss of a heartbeat.
He suggested that monitoring the heartbeat during contractions rather than between them might have identified this.
John Jordan, for the baby's parents, said they were happy with the way the inquest had been conducted and with the recommendations made.