RAYMOND Mackin and Anne Hearty had made plans for their life together.
Recently engaged, they were planning a wedding with family and friends in Malta and were excited about the impending birth of their baby. Thanks to a 3D scan, they already knew he was a boy and had chosen his name: Conall.
But their plans were shattered by dramatic and tragic events in September 2007.
Anne didn’t live to become a mother and her baby son was stillborn following a series of blunders by Daisy Hill Hospital and the consultant they hired privately to ensure a safe delivery.
Both the Southern Health and Social Care Trust and legal representatives for Dr Michael O’Hare agreed to pay Anne’s family an undisclosed sum at the High Court in Belfast on Monday October 3rd.
The deaths of mother and baby and the hospital investigations which took place afterwards raise fundamental questions about how the health service learns from catastrophes like this in maternity hospitals.
The Detail has investigated this case and discovered that:
• The trust failed to acknowledge following its own internal investigation that Conall had been in distress during labour or that this was picked up by a heart monitor five and a half hours before he was delivered by emergency caesarean section.
• The hospital’s internal review into the deaths praised the staff involved in Anne’s care for how they dealt with “a very rare and unavoidable emergency”.
• The heart trace graphs which were proof of a crisis labour were only handed over to the family six months after they requested them after realising they had been left out of the medical notes they originally requested.
• During the time Conall was in distress, Dr O’Hare didn’t check on Anne for a four hour period.
Deaths in childbirth are extremely rare. However, a preliminary hearing into an inquest opened on Tuesday into the death of another mother-to-be in June of this year at the Ulster Hospital in Dundonald.
Cara Officer, who was 36-years-old and 26 weeks pregnant, died along with her unborn baby.
The Coroner’s Office has told The Detail that a post-mortem examination confirmed that Cara’s death was “due to natural causes as a complication of pregnancy”. Her baby Ewan was stillborn.
WHAT HAPPENED TO ANNE AND CONALL?
Anne Hearty and Raymond Mackin lived in Dundalk but had decided to pay for private maternity care across the border with Dr Michael O’Hare who was based at Daisy Hill Hospital in Newry.
The pregnancy went smoothly. Anne went over her due date so Dr O’Hare booked the 27-year-old to come in to hospital to be induced on September 23rd, 2007. The induction took place the following morning.
After a long day in labour on a busy ward, Anne developed an infection. As would be normal, she was given the antibiotic Augmentin (penicillin). She had no history of allergies but immediately suffered a massive anaphylactic reaction.
In an interview with The Detail, Raymond said: “Anne complained she was getting sick and literally then within seconds her lips just started to swell up and she turned blue. She went really, really swollen and she just lay back in the bed. It was the stuff of nightmares.”
Anne was given adrenalin – which had to be sourced from another room – and resuscitation attempts began. A decision was taken to deliver the baby by emergency caesarean section. Little Conall was stillborn.
Anne was resuscitated and transferred to Craigavon Area Hospital but she suffered multi-organ failure and died on September 26, 2007.
Raymond (29) explained: “We were told that Anne wasn’t going to pull through. It was like being hit by a train. All the life was just sucked out of me and I just couldn’t believe it. I had nothing left inside.
“We went down beside Anne’s bed and I went up and said my goodbyes. I told her she gave me seven of the best years of my life and that I was glad she was with Conall.”
Anne and Conall were buried together – which gives Raymond some comfort.
He said: “Conall was in beside her and I’m glad he was buried like that. They were buried together and I know where ever she is she’d be a good mum. They have each other so I’m glad and they send me down some kind of strength to get on with my life.”
It was months later before Raymond, Anne’s parents and sisters discovered the full details surrounding the deaths of Anne and Conall. They were shocked to learn that the outcome could have been so very different.
Medical notes released to the family in December 2007 were missing 14 hours of graphs which recorded Conall’s heart trace during Anne’s labour. These graphs were eventually released to the family six months later after three solicitor’s letters.
The family were shocked to find that these crucial graphs – regularly read by midwives – showed that Conall’s heart trace was “grossly abnormal” from 5.30pm on September 24th. This should have led to his immediate delivery but instead he was delivered stillborn five and a half hours after this.
Anne’s father Gerard said: “Most of the experts have since said that Anne should have had a caesarean section between seven and eight o’clock that night. She had no infection at that stage which meant she could have had the caesarean section, the baby would have been out, she would have got the injection and she would have been in theatre and all the drugs were there to counteract the penicillin if she did take a turn.”
Anne and Conall’s deaths have had a major impact on the lives of her parents and three sisters.
Gerard said: “I was looking forward to having a second grandchild. The first one is spoilt but it wouldn’t have been hard spoiling the two of them. They’d have been great company for each other but it wasn’t meant to be.”
WHAT THE INQUEST REVEALED
An inquest was held into Anne’s death in September 2009. The coroner does not have jurisdiction to hold an inquest into a stillbirth so Conall’s death was not investigated, but the inquest did look into what his distress in the womb should have told medical staff caring for Anne.
Coroner John Leckey said the abnormal heart trace should have triggered prompt delivery of Conall. Three medical experts who gave evidence at the inquest – and Dr O’Hare – all agreed that the delivery could and should have taken place at a much earlier stage and that if that had happened it is very likely that Conall would have survived.
Mr Leckey said that assessing Anne’s chances of survival was “more problematic”. He concluded that irrespective of the time of Conall’s delivery and the promptness of the resuscitation her chances of survival would have been remote.
WHAT THE CIVIL ACTION REVEALED
The family, however, pursued their search for answers by suing both the trust and Dr O’Hare for clinical negligence. Their claim was backed by a medical expert they consulted who also believed Anne should have survived.
Richard Pyper, Consultant in Obstetrics and Gynaecology at Worthing and Southlands Hospitals NHS, Trust concluded in his report: “If the baby had been delivered in a timely matter, he would certainly have survived. It is probable that his mother would have survived as well.”
He claimed that Conall not being delivered until five and a half hours after the fetal trace was first classed as abnormal “represents a breach of duty by both the midwives and Dr O’Hare.”
Mr Pyper also said that Dr O’Hare “seems to have been over-committed that evening with three private patients in labour on delivery suite”.
And he said: “I find it very hard to understand why he could not find a few minutes to review Mrs Hearty between 17.45 and 21.35, a period of almost 4 hours.”….”The CTG (heart trace) was already abnormal at 17.45 when he saw the patient and I find it very surprising that he did not go back and review the patient as often as he could throughout the evening.”
In his report dated March 2010, Mr Pyper also raises concerns about staffing in the hospital.
It is recommended that an obstetric registrar should be available 24 hours a day with a consultant obstetrician for support at all times but he concludes: “It seems that this hospital did not fulfil these criteria for safe care on the labour ward. If this issue is not addressed, it is likely that further disasters will occur.”
THE TRUST’S INVESTIGATIONS
The Southern Health and Social Care Trust’s first investigation into Anne and Conall’s death was an internal review which aimed to establish if there were any deficiencies in the care provided and to make recommendations to improve patient care.
The investigation panel reviewed all ante-natal and labour records, took statements from staff and sought expert opinion.
Despite this extensive review, the report’s conclusions and recommendations make no mention of Conall’s heart trace.
The panel conclude that “there were no care delivery problems or service delay problems identified which directly impacted on baby Conall Mackin.”
They go on to commend all staff involved in providing care to Anne and Conall who had to deal with “a very rare and unavoidable emergency”.
The chief executive of the trust then commissioned a ‘root cause analysis’ of the care of Anne and Conall. This is a structured investigation which is meant to identify the true cause of a problem.
Two largely similar root cause analysis reports – dated May 2008 and June 2008 – were produced.
However, once again, the focus of the investigators was on Anne’s severe reaction to the antibiotic and no mention is made of concerns about Conall’s heart trace many hours before he was delivered.
The team claimed that Anne had “an uneventful first stage and early second stage of labour” – which is also at odds with the fetal heart monitoring.
Gerard Hearty said: “The trust said that Anne had an uneventful first and second stage in labour which wasn’t true and they commended their staff for the management and care that Anne received.”
We asked the Department of Health for a comment on root cause analysis and whether it actually works.
A department spokesman said: “Root Cause Analysis s a widely used investigative technique within health and social care, both here and elsewhere in the United Kingdom. The department supports its use where appropriate.
“It provides a structured and consistent approach to incident investigation across all care settings and helps to focus recommendations as a result of identifying the root cause/causes of an incident.”
In relation to the Anne and Conall’s deaths, the spokesman said: "The department does not comment on individual cases.”
THE COURT PROCESS
The Mackin and Hearty families finally received some closure on Monday when a settlement was agreed at Belfast’s High Court following hours of negotiations between the legal teams. The settlement amount has not been disclosed.
Proceedings continued at the High Court on Tuesday over how the damages should be divided between the trust and Dr O’Hare.
A spokesperson for the Southern Health and Social Care Trust issued a statement on Tuesday evening which said:
“The Trust wishes to extend its deepest sympathy to the partner and family of Anne Hearty and baby Conall. All of the staff involved in their care have been extremely saddened by these events.
“Along with our own investigations, Trust management and staff have fully participated in all legal proceedings and have reached a settlement with the family.”
It has been a long battle for the Mackin and Hearty families.
Raymond said: “We’ve had to fight all the way to get answers. We don’t want another family to have to go through what we’ve gone through.
“I feel like that night in the hospital they were severely stretched. It’s not like a garage where you put cars, this is human lives you are talking about. Is it too much to ask for another doctor to be on duty or a couple of extra staff? I’ve been left in a living nightmare over this and I’m living with it every day.”
Speaking outside court on Monday, Raymond said: "It has been a tough four years. We had to go the whole way and ask a lot of questions and seek a lot of expert advice.
“I am glad the case is over and done with. Now I can try to pick up the pieces and try to get on with my life.”
Anne’s dad Gerard said: “I feel very relieved we have got closure. It will never go away but hopefully we can move on.”
The family’s solicitor Catherine Allison said: “Private patients paying for private care expect a superior level of care. In reality, the care Anne received was worse than inferior and caused the unnecessary deaths of a mother and baby.
“Anne was weak, distressed, tired and hungry and developed an infection essentially because of their failure to deliver the baby.
“The trust’s own investigation hardly touched the surface and praised the staff for the quality of care and said nothing went wrong. The family just wanted accountability for the deaths of Conall and Anne.”