An inquest into the death of a full-term stillborn baby at Mayo University Hospital has returned a verdict of medical misadventure at the Coroner's Court in Swinford.
Marion and Robert Hunt from Castlebar say their daughter's death could have been avoided if there was a proper standard of maternal care in place.
Coroner Eleanor Fitzgerald recommended the use of monitors for high risk pregnancies from the beginning of induction of labour.
Ms and Mr Hunt named their baby girl Amelia Rose. The couple already had two boys and this was an IVF pregnancy following two miscarriages.
The baby was stillborn at 38 weeks and three days in December 2023.
Ms Hunt was visibly distressed throughout the inquest as she clutched a framed photo of Amelia Rose.
She told the court that her baby was perfectly healthy and she had been vigilant thoughout the pregnancy.
She had been under the care of Dr Tarig Awadalla, Consultant Obstetrician at MUH. She had complained of reduced fetal movement on three separate occasions in the final weeks of pregnancy and was identified as "high risk".
Ms Hunt was admitted to hospital on the 27 December 2023 and her labour was induced. The baby was over 38 weeks and 3 days and described as "large for fetal age".
Over the morning of 27 December, she developed contractions but by lunchtime the baby's heartbeat could not be detected and an ultra sound confirmed intra-uterine fetal death.
The baby was delivered the following day with a short umbilical cord wrapped tightly around her neck and body. Her death was described as a "cord accident".
During cross examination, it was put to Dr Awadella that given the mother's older age of 43 years, given this was an IVF pregnancy and given she had developed polyhydramnios, a condition showing excessive amniotic fluid, she should have been offered the options of an earlier induction or an elective caesarean section.
There had also been concern during an antenatal clinic visit on 14 December about the risk of shoulder dystopia where the baby's head is delivered but the shoulders remain 'stuck' in the birth canal.
The court heard that induction of labour was an option that might also have been considered at that stage
The consultant said there had been no immediate danger and that he was trying to do his best for mother and baby by inducing labour before 39 weeks.
Senior Counsel for Mayo University Hospital Luán Ó Braonáin said the sense of loss was felt by everyone today including the nurses and midwives in attendance at the inquest who were visibly upset and distressed as they recounted details from 2023.
He went on to call for a verdict of death by natural causes saying medical intervention hadn't caused what was described in court as a "cord accident".
Solicitor for the Hunt family Damien Tansey said that clearly what happened was not intentional but something had gone wrong and the appropriate verdict was medical misadventure
He said: "This was a high risk pregnancy by definition, acknowledged by the hospital and the consultant in the hospital, and it became more serious in the last month before the death.
"And you heard the coroner there in arriving at her decision of medical misadventure, that the option of a cesarean section at an earlier stage should have been presented to Marion as an option.
"And in fairness to the consultant, he also agreed that he should have given that option, and he regretted not doing so.
"And clearly, had the option of a cesarean section been presented to Marion she would have opted for it, and we wouldn't be here today."
The coroner said there were warning signs and management deficiencies regarding discussions and counselling about the risks and alternatives offered that may have altered the outcome for Marion and Robert
'We fought so long, so hard for this'
Ms and Mr Hunt spoke outside the courthouse surrounded by family and friends. Ms Hunt said Amelia Rose got justice today.
She said: "We're totally relieved because we've fought so long and so hard for this.
"Amelia deserved justice, because what happened to her wasn't right, and we feel that today has vindicated us and shown that there was things that could have been done.
"And it's been a long time, but we are here now, and we have justice for her, and we fought for that specifically for her, because we didn't want this to happen to another family and another baby.
"In 2026 this shouldn't be happening, and we want to make sure that no other family go through this, and we have justice for her."
Ms Hunt looked at her framed photo of Amelia Rose and said: "She's a beautiful little girl, you can see from pictures.
"She was a perfectly healthy baby girl. No reason why she shouldn't be here, but if this loss prevents other people and other families going through it, it'll have been worth fighting all the way to here, for this."
Her husband Robert wiped his eyes and held Marion closely and said: "Today was about getting answers, getting answers for us in the sense of knowing what happened, and then you know getting the recommendations from the coroner, and the fact that something is going to change that's going to prevent this happening to another family going through what we've just talked through."
