Legal row erupts over cause of death of day-old ‘perfectly formed’ baby girl

The baby, Sofia Wlodarczyk, died in the arms of her parents at the Rotunda Hospital in Dublin on March 23, 2019, less than 24 hours after her birth at Our Lady of Lourdes Hospital in Drogheda, Co Louth.

The coroner, Clare Keane, returned a verdict of death due to natural causes “on the balance of probability” at the end of a two-day hearing at Dublin District Coroner’s Court involving “very complex” medical evidence.

Dr Keane said the baby was born with no signs of life, but she had heard evidence that factors that had contributed to her death had occurred before her delivery.

Lawyers for the baby’s parents, Katarina Hubayova and Marcin Wlodarczyk, had claimed complex and challenging efforts to resuscitate Sofia after she had no heartbeat at the time of her delivery were a contributory factor in her death.

Counsel for the family, Roger Murray SC, said evidence heard over a two-day inquest at Dublin District Coroner’s Court had revealed that it had taken 37 minutes before a heartbeat had been restored.

Mr Murray pointed out that she had a perfectly normal heartbeat up to 12 minutes before her birth at 2.22pm on March 22, 2019.

He outlined how a consultant paediatrician had not attended to help with the resuscitation until five minutes after the baby’s delivery.

Although adrenaline had been given to the baby earlier using a tube, Mr Murray said the drug was only administered using a needle into her bones at 2.38pm and again two minutes later through the umbilical vein after a number of unsuccessful attempts.

The barrister said no attempt to suction meconium [the first bowel movements of newborns] from the baby’s lungs had been made until 2.42pm.

“It is a situation where every second counts,” Mr Murray said.

He urged Dr Keane to consider a verdict of medical misadventure as the ­baby’s death appeared to be linked to an unintended outcome of the course of treatment provided to her at the hospital.

However, Mr Murray accepted that a narrative verdict was also appropriate given the complexity of the case.

Counsel for Our Lady of Lourdes Hospital, Rebecca Graydon BL, expressed surprise that the baby’s family considered she had died as a result of a sudden event around the time of her delivery as she claimed the evidence suggested otherwise.

Ms Graydon, who called for either a verdict of death due to natural causes or a narrative verdict, said the evidence of a pathologist who carried out a post-mortem on the baby indicated any issue with meconium was present for a minimum of four to six hours before her birth. She added that it had been unhelpful for Mr Murray to suggest there was a “mystery” over how a perfectly formed baby had died.

Pathologist Noel McEntagart told the inquest that Sofia had died as a result of an acute lack of oxygen to the brain around the time of her delivery.

He attributed the injury to a combination of poor blood flow in the foetal blood vessels, abnormal coiling of the umbilical cord and an inadequate blood supply to skeletal muscle due to meconium.

In reply to questions from the coroner, Dr McEntagart said it was impossible to date when the problem of the abnormal coiling had started, although it usually occurred in the third trimester of a pregnancy.

The pathologist also confirmed that it was not something that could be detected by an ultrasound scan. Dr McEntagart claimed the ­relatively small size of the baby at birth could be linked to some of the in-utero complications that he estimated may have occurred 12 to 48 hours before her delivery.

Cross-examined by Mr Murray, he acknowledged that the exposure of the baby’s blood vessels to meconium would have exacerbated her condition.

Asked if the complexity and challenge of resuscitation efforts, including the lack of a heartbeat for 37 minutes and the presence of meconium in the baby’s lungs, had also played a role in her death, Dr McEntagart replied: “It would not have helped matters.”

In earlier evidence, a consultant paediatrician at Our Lady of Lourdes, Dr Emma Gordon, said the ability of medical staff to have intubated the baby within two-and-a-half minutes of her birth was “excellent”, given she had no heartbeat at the time of delivery.

Dr Gordon pointed out that research had shown the average time taken in such cases is 3.8 minutes.

The consultant told Dr Keane that the team of doctors had followed a dedicated protocol in their attempt to resuscitate the baby.

A neonatologist at the Rotunda, Adrienne Foran, said she had assessed Sofia as having suffered ­severe brain damage from a lack of ­oxygen, which had also affected her heart and kidneys.