Verdict of Medical Misadventure at the Inquest into the death of Baby Luke Duffy who was tragically delivered stillborn on the 30th of October 2018 at the Midlands Regional Hospital, Portlaoise.

Liston Flavin LLP represented the parents of baby Luke Duffy who sadly was stillborn on the 30th October 2018 at Portlaoise Hospital. Luke’s mother, Lisa Duffy, was under the care of the obstetric team in Portlaoise Hospital throughout her pregnancy.

Lisa was due to be induced at 38 weeks, however when the induction was being booked the only available date was Monday 29 October 2018, which was a bank holiday, and at which stage Lisa would be 39 weeks plus 2 days pregnant.

Prior to the induction date, Lisa attended Portlaoise Hospital for ongoing antenatal care on the 23rd and 24th of October 2018. On both occasions there were issues with her test results and her blood pressure was high. As a result, she was told that her induction would be brought forward to Friday 26th October 2018.

On the 26th October 2018 Lisa attended in Portlaoise Hospital. She was admitted to Hospital that evening. Despite the previous plan that she would be induced that day, and despite her having contractions, she was told that her induction would now not take place until Monday 29th October 2018. Throughout the weekend Lisa complained of back pain and requested an earlier induction of labour. No vaginal examination was carried out by the hospital between Friday 26th October 2018 and Monday 29th October 2018, nor was Lisa assessed by a Consultant Obstetrician during that period. The medical records show that baby Luke was alive between 7am and 8.50am on the morning of 29 October 2018, however tragically, intrauterine fetal death was diagnosed by a scan later that morning and Luke was delivered stillborn on the 30th October 2018.

An inquest was held into the death of baby Luke. During the Inquest, the hospital apologised for the failings in care and ultimate death of baby Luke Duffy. The hospital further accepted that his death should not have happened and that it sincerely regretted the tragic consequences for Baby Luke and his family.

The Coroner returned a verdict of medical misadventure and recommended that on-site consultant expertise should be available at all times for obstetric units and should be accessible to medical staff and the nursing and midwifery teams of these units. In relation to Lisa’s experience of persistent back pain not being acted on as an indicator that she was in labour, the Coroner also recommended that there should be regular training on the signs of labour to include the fact that, at any particular time, the primary indicator or the only indicator of the commencement of labour can include back pain.

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