A verdict of medical misadventure has been returned at the inquest into the death of a baby hours after she was born at St Luke's Hospital in Kilkenny in 2014.
The jury in the inquest at Kilkenny Coroner's Court has recommended that "good communication practices" between medical professionals in emergencies be implemented and also that patients, whether public or private, have access to appropriate and timely medical care.
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The inquest into the death of baby Livia Urkova Marini heard that her mother, Ludmila Ukova, had a condition called vesa previa.
The condition is difficult to diagnose prior to labour, the inquest heard during a previous hearing. It involves the baby's head pressing down on the womb membrane and the blood vessels running between the baby and the placenta.
If the blood vessels are near the neck of the womb, there is a risk of a tear once labour starts and the womb neck opens. In this event, foetal blood is lost.
That is what happened in the case of Ms Ukova who went into labour on the morning of 18 May, 2014.
The coroner, Tim Kiely, directed the jury to return a verdict of medical misadventure, that that the death of baby Livia was as a result of the application of a "kiwi cup" attempted vacuum delivery "which was a medical error or medical mishap".
The application of that vacuum cup had the "unintended outcome of causing a bleed which led to the death of the child", Mr Kiely said.
He added that returning a verdict of medical misadventure "does not infer any fault" on the part of any medical professional.
"It was the unintended consequence, which was the death of the child, from the intended action, which was the use of the kiwi cup."
The inquest previously that Ms Ukova was well-dilated in labour by 8.45am that morning after being admitted to St Luke's Hospital and there were "decelerations" in her baby's heart rate during the morning.
By 11.10am, midwives found that the baby's heart rate was 60bpm (beats-per-minute_, having earlier been 130bpm, and her cervix was "almost fully dilated" but not fully dilated.
A number of phone calls were made to the consultant obstetrician on duty at the time, and the registrar.
The inquest was told by midwives that the protocol was that they would initially call the registrar on call to review a public patient.
"If it's a private patient you would contact the consultant," midwife Emma Murphy said in evidence during a hearing last year.
The registrar, Dr Ali Gerwash, arrived at 11.10am and attempted two "kiwi vacuum" deliveries, using a kiwi vacuum cup, but was unsuccessful.
The consultant, Dr Yuddandi Nagavini, arrived at 11.55am and found a "faint" foetal heartbeat. She performed an emergency caesarian section and delivered baby Livia at 12.04pm, but the baby was in poor condition.
She was placed in an incubator in the baby special care unit and there were discussions at the time about moving her to the National Maternity Hospital but she "collapsed," her heart rate went down to zero and a decision was made in consultation with her parents to discontinue ventilation support. She died at 7pm that evening.
Raymond Bradley, solicitor for the parents Ms Ukova and Aldo Marini from Carlow town, said today that the inquest had "highlighted the dichotomy in standards of care between public and private patients".
He described it as a "two-tier system, and that is a policy" and asked the jury to recommend an end to that policy.
"You are charged," he told the jury, "with a very important duty and obligation to make recommendations from the circumstances of this inquest to prevent a repeat of these events and, hopefully, change the health care system for the betterment of your own sisters, your daughters, your friends' sisters and daughters, when they go into the maternity section."
He said it is incumbent on the Health Service Executive to take a message from this inquest.
"Consultant-led care is a right for citizens, it's not an option. Especially in maternity services," Mr Bradley said.
Barrister Paul McGinn, for the HSE, said they agreed with a recommendation that all obstetric patients, either public or private, should have access to "appropriate and timely medical care" in hospitals.
He did not agree with the argument that these circumstances gave rise to allegations of a "two-tier system," Mr McGinn said. "It's more a communication issue than the system itself."
The inquest heard during evidence last year, from midwife Emma Murphy, that Dr Gerwash's manner when he arrived in the ward was "inappropriate and unhelpful".
The doctor himself denied that he had "declined" to review the patient when contacted by phone by the midwives, and did not ignore calls made to him, but that the plan of management of the patient had been changed without him being informed.
Returning their verdict, that death was as a result of birth asphyxia and haemorrhagic shock, secondary to vesa previa, the jury also recommended that scans be carried out to ascertain the risks of vesa previa, as indicated by medical practitioners, where appropriate.
Offering sympathy to baby Livia's parents, who do not have any other children, the coroner described the case as "an indescribable set of circumstances" and extremely difficult for all involved.
"None of us can countenance the loss of a child, particularly a child of such a young and tender age," he said.
