The death of a six-day-old boy was avoidable, a coroner has ruled, ending what his parents described as a long and arduous search for the truth about the tragedy.
Baby Troy Brady died after suffering catastrophic brain damage as he was being delivered in Craigavon Area Hospital in August, 2016.
Coroner Maria Dougan found that the death was avoidable as she noted the decision by the consultant obstetrician to place mother Jane in on all fours position, a manoeuvre he had witnessed but never performed before and in a high risk situation where the baby was premature and in breech.
“Our search for the truth has been long and arduous,” Mrs Brady and father, John, said following the hearing at Laganside on Friday afternoon. “Our loss continues.”
“Troy Brady was born on the 19th of August 2016, and died on the 25th August, 2016. We have lived since this date without our son and three sons have lived without knowing their big brother. Remember Troy Brady, rest in peace,” they said in joint statement read by their lawyer, Laurence McMahon.
The coroner found that Dr Rohit Sharma, the obstetrician in charge, failed to discuss the method of delivery with the parents or staff and “lacked the required experience” to carry it out in a hospital where it had never taken place.
The inquest heard that after delivering Troy up to his neck, the head became stuck and the decision had to be taken to turn Mrs Brady on to her back. Forceps were used to fully deliver the baby.
Ms Dougan found that the death was avoidable, citing the delay caused by the mother being moved from the position she was in and on to her back. Lack of oxygen to the brain caused hypoxic-ischemic encephalopathy.
The coroner also found that there was a lack of communication between hospital staff and the parents, including a failure to fully detail the risks of breech delivery and that they were not fully informed on whether to have a caesarean section birth.
She added that all trusts should consider providing guidance and detailed information on informed consent where there are high risks before parents reach the labour ward.
Her findings largely reflect the conclusions of three medical experts, all of whom were critical of the method of delivery and the failure to provide full information so the parents could give informed consent.
Mrs and Mr Brady, from Coalisland, Co Tyrone, praised the coroner for the “thorough diligent and sensible” way she conducted the inquest , which ran for three days in April.
They said when reflecting on the “traumatic events of Troy’s birth and subsequent death” they wanted to know the truth as to what happened to our baby son, how it happened and how it can be avoided in the future.
“We believed then and we believe now there were failings in the care provided both before and during Troy’s traumatic birth,” they said.
“It is our wish that no other family will endure the pain and loss that we have endured.”
They said the doctors “in charge of delivery should discuss the mode of delivery directly with expectant parents. This did not happen in our case”.
“The attendant obstetrician in charge of the delivery should have planned and discussed the mode of delivery with all other doctors, midwives and support staff in timely fashion before delivery. This did not happen in our case.”
Expectant parents should be provided with information “regarding the level of experience of a doctor in any procedures or manoeuvre they plan to use”, the parents said.#
In a statement to the Irish News, a Southern Health and Social Care Trust spokesperson said: “We extend our deepest sympathies to the Brady family on the tragic death of Troy in 2016.
“We have participated fully in this extensive inquest process and accept the Coroner’s findings. We will review the Coroner’s written findings in detail when completed.
“In recent years, we have made changes to our procedures regarding communication between our staff and families particularly around delivery options.”
