An inquest into the death of a newborn baby boy has been told that his death was not down to one simple error, but to a series of missed opportunities.
A verdict of medical misadventure was returned in the death of Eli Hunt, who died 13 days after he was born last October at University Hospital Waterford.
At the Coroner's Court in Cork today, the hospital and the Health Service Executive apologised to the family for the care given.
They acknowledged the experience was devastating and had a profound effect on the family.
The court heard that although first-time mother Krystal Hunt had a Group B Strep infection, was running a temperature and had an abnormal heart beat when she was first admitted, it was seven hours before a decision to carry out an emergency caesarean section was made.
Mrs Hunt told the court that she and her husband Trevor were given no information about their son after his birth and waited in the recovery room for nearly two hours not knowing if their baby was alive or dead.
They only learned how critical ill he was, when he was moved to Cork University Maternity Hospital for specialised care and a consultant there spoke to them.
Consultant Obstetrician and Gynaecologist at UHW Dr John Bermingham, who was not on duty on the night, but reviewed the file, said it was not just down to one simple error, but was down to a series of missed opportunities.
He said it was clear to him that baby Eli should have been delivered up to seven hours earlier, saying the presentation of a patient in labour with an elevated temperature should have been a clear warning that delivery should be expedited.
Dr Sarah Muddasser who was the Registrar on duty that night told the court that she had worked in obstetrics since 2006. She said she did not attend Mrs Hunt herself because she was busy and was re-assured by the information she was given.
She accepted the findings of a review team that the consultant on call should have been contacted and that a caesarean section should have been done sooner due to the mother's Sepsis infection and abnormal foetal heartbeat readings.
She apologised to the parents saying she personally made decisions that night which turned out to be incorrect and she will have to live with that knowledge for the rest of her days. However, she said, it is nothing to the upset and anguish of Eli's parents.
Brenda Kavanagh, the operations manager at WUH, said the management team had taken baby Eli's death to heart.
An external review was ordered and seven recommendations have, or are in the process of being implemented.
Dr Peter Kelehan, who performed a post-mortem examination said the cause of death was brain damage due to an inflammatory response due to ascending amniotic fluid infection arising from the Group B Streptococcal infection.
Speaking afterwards, Ms Hunt said all she and her husband wanted as parents was for Eli to arrive safe and healthy.
She said she can only hope that lessons will be learned from what happened to them.