'We left the Rotunda looking for a graveyard' - couple in baby tragedy
The parents of a baby stillborn at the Rotunda Hospital say part of them also died the day that they lost their son.
Cintia Reina and Alan Chagas, originally from Brazil but now living in Phibsboro, Dublin 7, said they want to make sure another baby doesn't die in similar circumstances.
Arthur Reina Chagas was unresponsive when he was born just before 9pm on March 28, 2018.
A verdict of medical misadventure was returned at an inquest into the baby's death at Dublin Coroner's Court.
Arthur's mother said she repeatedly asked for her baby to be delivered by caesarean section because he was in distress.
"We went to the Rotunda to have our baby Arthur but we left the hospital with empty arms and looking for a graveyard," she said, speaking after the inquest.
"I asked for my baby to be delivered by C-section many times but nobody listened to me and my baby died in my belly. The CTG traces were not read properly when our baby was in distress.
"Things must change, babies cannot keep dying. Something needs to be done.
"We have lost our son and we want to make sure that this doesn't happen again."
Ms Reina added: "Part of us is dead since our son died and we feel we die a little more every day."
A resumed inquest into Arthur's death heard that the consultant on call was not contacted and the senior registrar was too busy to review the baby's condition in the lead-up to his birth. Senior registrar Dr Mohamed Elshaikh told the inquest that he was "too busy with other patients".
Asked why he did not contact the consultant on call, Dr Elshaikh replied: "I didn't call him."
The inquest previously heard that obstetric staff were busy with an instrumental delivery during this time.
Two midwives said they did not inform the consultant on call.
Both said they were waiting for doctors present on the ward to become available to assess Ms Reina.
Arthur's heart rate dropped to a dangerous level by 8.43pm. He was stillborn following an emergency caesarean section performed at 8.59pm.
A post-mortem found he died due to an acute hypoxic event between four and six hours before delivery. The cause of this event is not known.
The inquest heard of complications relating to electronic note-taking systems at the hospital.
Master of the Rotunda Hospital Professor Fergal Malone admitted there were inefficiencies in the electronic system but said that overall its introduction had brought a "significant increase in efficiency".
Prof Malone outlined a number of changes implemented at the hospital since Arthur's death, including ongoing education on the electronic note systems and the implementation of regular 'patient safety huddles' for staff to discuss the best use of communication tools.
Returning a verdict of medical misadventure, Coroner Dr Myra Cullinane endorsed the changes at the hospital and recommended the reinforcement of reliance on full clinical information rather than sole reliance on the CTG trace to monitor foetal well-being.