A coroner has found that there were various missed opportunities in respect of care by doctors and midwives to a baby which was stillborn.

Karl Lee Morton was stillborn at South West Acute Hospital on November 16, 2014 as a result of placental infarction and retroplacental haemorrhage/placental abruption.

In evidence to the inquest, Miss Sarah Morton, mother of the deceased stated she had two previous successful pregnancies although she did suffer from pre-eclampsia and had an emergency caesarean section with her first born. Her second child was born two weeks early and Miss Morton had Strep B at that time. Both children were small for gestational age with the first child particularly so.

The inquest heard Miss Morton had found pregnancy easier than the previous two with no morning sickness or nausea. At her 20 week scan she recalled being informed that everything was fine and that her baby was progressing well.

At around 23 weeks, Miss Morton began to experience severe headaches resulting in her attending Accident & Emergency (A&E) Department at SWAH on August 26, 2014. She was prescribed paracetamol, but she declined as she did not generally like to take medications during pregnancy.

She again attended on September 4, 2014 and mentioned no fetal movement. She underwent a scan at a fetal assessment unit where movement and heartbeat were confirmed.

On September 10, she attended the midwife for tests and fetal heart was heard.

Some two weeks prior to the birth Miss Morton began to feel unwell. She had a severe headache on November 4, and she believed she attended Out of Hours GP that night although no record of any such attendance could be located.

Then she attended A&E on November 6 complaining of vomiting, headaches and blurred vision and paracetamol was given.

From this point she recalled attending her GP, A&E and Out of Hours (OOH) GP on numerous occasions. She experienced back pain and the headaches never settled. In relation to the back pain she stated this started on November 8 and by November 9 the pain was severe. She drove to her uncle’s house as she could not make it to the hospital, and she had to be brought into the hospital in a wheelchair.

She stated in evidence that she believed the last time she felt fetal movement was on November 12 and that she had no concerns with the movement on that date. On that date Miss Morton attended her GP followed by A&E and then OOH GP.

Miss Morton recalled being well enough to go Christmas shopping in Omagh on November 13. That afternoon she attended the 36-week scan. Before her meeting another doctor scanned Miss Morton and after that she was informed that her child had passed away. In a note in the records it stated that ‘Ms Morton says the last time she felt movement was last night’ which would have been November 12.

In his findings at the inquest Coroner Patrick McGurgan stated on numerous occasions that opportunities were missed in respect of the care given to the mother and unborn baby.

Mr. McGurgan said that he found the referral form completed by Miss Morton’s GP was deficient and that forms should include “all relevant information” and to make no assumptions about what information others may have or may not know.

The coroner found that the midwife who initially booked Miss Morton had acted appropriately at the time given the restraints on her as regards accessing computerised notes.

However, he found that on a further appointment on September 24, 2014 the midwife failed to appreciate the significance of the two previous birth weights and that by doing so missed an opportunity to refer Miss Morton to the Consultant with a request for a scan.

Mr. McGurgan found that at other points during her pregnancy doctors and another midwife had opportunities in respect of care which were missed including by her Consultant and at the times she was in A&E or OOH GP.

The significance of the weight of Miss Morton’s two other children was seen as a key piece of information which was not picked up during a visit to hospital on November 6, 2014 as well as a failure to take a full and detailed medical history from Miss Morton.

The coroner also found at another attendance at SWAH Accident & Emergency on November 10, Miss Morton should have been examined more thoroughly and referred to Obstetrics and Gynaecology and failing to do so was another missed opportunity.

Mr. McGurgan said that the evidence suggests that pregnant mothers should be reminded at all times to bring their folders with them to medical contacts be this when being phone triaged by OOH GP service, ambulance contact or at any other relevant opportunity.

In addition, the evidence suggests that any attendance with a medical professional should be recorded in those notes together with the outcomes of the attendance.

Alternatively, a copy of the medical record should be given to the patient on discharge so that they can insert it into the maternity folder and this should be the policy in every Trust.

Mr. McGurgan found that the deceased became “stressed” at approximately two weeks prior to his death, that brain damage occurred some four to five days prior to death and that death occurred some three to four days prior to delivery.

By not being placed on a Consultant led pathway, the coroner found that Miss Morton was deprived of the opportunity for scans and checks to have taken place during the period when the baby was “stressed” and that this represented a loss of opportunity in respect of the care and treatment of the deceased.