The mother of a baby delivered stillborn at the Midlands Regional Hospital in Portlaoise almost five years ago has criticised the standard of care she received at the hospital during her pregnancy.
Giving evidence at a sitting of Laois Coroner's Court, Chelsea Brereton said she left the hospital "broken, confused and consumed with grief," on 15 April 2020 after being informed that her baby boy was dead in her womb.
Baby Mason Dunne was full term when he was delivered stillborn at the hospital the following day.
During evidence today, Ms Brereton from Sallins, Co Kildare, was highly critical of the care she received at the hospital in Portlaoise.
She also criticised the fact that her baby's organs were retained after a post-mortem, against her wishes and those of her partner Jamie Dunne.
Evidence critical of care
The inquest heard Ms Brereton was discharged from the hospital five days before learning her son had died in her womb at a time when she had "begged" for labour to be induced.
Consultant gynaecologist, Shoba Singh, gave evidence that she had not checked the patient’s medical history before discharging her and was also unaware of the baby’s foetal movements.
The family’s counsel, Sara Antoniotti SC, noted that the patient would have received regular monitoring that would have picked up a problem with the foetus if she had not been discharged on 10 April 2020.
Ms Antoniotti said guidelines had been breached by Ms Brereton being discharged without any medical review and against her maternity plan.
The inquest heard Ms Brereton returned to the hospital on 15 April 2020 when she did not feel much movement with her baby.
She told the inquest that because of restrictions during the Covid pandemic she was alone when a consultant told her that her baby had died.
Mr Brereton claimed Dr Singh came into a room and spoke over her about the result of a scan and said: "It's dead. No heartbeat."
She recalled feeling her own heart stop and starting screaming while her partner was waiting outside "with no idea of the horror unfolding".
Ms Brereton said Dr Singh went "absolutely mental" when she told her partner to come into the hospital and disputed as "false" medical records which stated that the couple were offered condolences and allowed time and space to grieve.
Verdict
Recording a narrative verdict, the coroner Eugene O’Connor said he would propose detailed recommendations at a later stage in relation to procedures governing post-mortems and training.
The coroner observed that there had been "some shortcomings" in the care of Ms Brereton and noted she had "a difficult experience with a difficult pregnancy".
He claimed there was also a need for an update "with some urgency" of the guidelines regarding the induction of labour.
The coroner heard there was a conflict of evidence between Ms Brereton and hospital staff over aspects of her care including whether she was offered a cervical sweep to induce labour.
Counsel for the hospital, Conor Halpin SC, suggested the patient had a "flawed recollection" about being in agony when she was discharged on 10 April 2020, already past her due delivery date.
The inquest heard evidence from hospital witnesses that there was no concern about discharging Ms Brereton as she was not experiencing any bleeding, contractions or reduced foetal movements.
However, Ms Brereton told the inquest that she was in excruciating pain and begging for help. Asked by Mr Halpin if she had medical qualifications, she replied: "No but I know my body better than anyone else."
Post-mortem examination
Pathologist John Gillan, who carried out the post-mortem examination, said the baby had died as a result of hypoxia or a lack of oxygen.
Dr Gillan estimated that the death occurred no more than 48 hours before the lack of the foetal heartbeat was detected.
He was questioned about the retention of some of the baby's organs against the family's wishes and he said he was never aware about the request for the baby’s organs not to be retained.
However he stressed organs are retained for very exhaustive examinations of an unexpected and unexplained death.
The pathologist described the long delay in returning Mason’s body parts to his family as "a fiasco" which was "highly regrettable".
Dr Gillan told the inquest that he had not been able to examine the organs for over a year after the baby’s death due to an exceedingly high workload.
He attributed the failure to inform Mason’s family about the retention of the organs due to the departure of a specialist laboratory technician and "mismanagement".
However, Dr Gillan said there was now a register in place relating to any retention of organs.
Earlier in the hearing, Counsel for the hospital, Conor Halpin SC, clarified that a form - used in cases where a post-mortem and a coroner's report is required - has been changed and updated at the hospital since January 2024.
Difference in care
The inquest heard Ms Brereton became pregnant with her daughter Kayla while she was still waiting to get answers to questions about her son’s death from the hospital in Portlaoise.
She told the hearing that the change in care she experienced while attending the National Maternity Hospital in Holles Street in Dublin for her second pregnancy was "astonishing".
Ms Brereton said both Kayla and another daughter, Emily, were born alive and healthy in Holles Street.
"It is my strong belief that if the Midland Regional Hospital in Portlaoise had acted in the same manner as the National Maternity Hospital, Holles Street, that my son would have been born alive and healthy and I would have him in my arms today," she said.
She also told the inquest that the findings of the post-mortem on Mason's body were never explained to her and her partner and they had to resort to Google to try understand what happened.
She said 20 months after his death they learned that Mason's brain, left lung and intestines had been retained without their consent.
Ms Brereton told the inquest that they had to open their son's grave a second time, five days before Christmas.
Following the inquest, Ms Brereton said nothing would bring their beautiful son back but the verdict has to result in the Midland Regional Hospital in Portlaoise and the HSE "learning from their mistakes".
