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| Doctor U-turn at hospital inquest | Doctor U-turn at hospital inquest |
| (10 minutes later) | |
| An anaesthetist, who told an inquest a woman may have died after self-administering too much morphine, has conceded this was not the case. | An anaesthetist, who told an inquest a woman may have died after self-administering too much morphine, has conceded this was not the case. |
| Dr Susan Atkinson's original evidence was heard on Monday, the first day of the inquest into Janet Brown's death. | Dr Susan Atkinson's original evidence was heard on Monday, the first day of the inquest into Janet Brown's death. |
| The 28-year-old from Lisalbanagh Road, Magherafelt, died after giving birth at Antrim Area Hospital in September 2006. | The 28-year-old from Lisalbanagh Road, Magherafelt, died after giving birth at Antrim Area Hospital in September 2006. |
| Mrs Brown had been given a device to administer the drug following an emergency caesarean section. | Mrs Brown had been given a device to administer the drug following an emergency caesarean section. |
| On Monday, Dr Atkinson told the inquest that she had a number of safety concerns about the device, including the possibility that a patient could accidentally administer a lethal dosage. | |
| In a dramatic U-turn on Tuesday, Dr Atkinson re-entered the witness box at the Coroner's Court. | In a dramatic U-turn on Tuesday, Dr Atkinson re-entered the witness box at the Coroner's Court. |
| It followed an appeal from barrister David Sharpe, acting on behalf of the company which manufactures the device, in relation to what he termed "adverse coverage prior to the hearing of any evidence". | It followed an appeal from barrister David Sharpe, acting on behalf of the company which manufactures the device, in relation to what he termed "adverse coverage prior to the hearing of any evidence". |
| Mr Sharpe asked that Coroner John Leckey reconsider his call, prompted by Dr Atkinson's evidence, for the Baxter Patient Controlled Administration (PCA) device to be removed from hospital use. | Mr Sharpe asked that Coroner John Leckey reconsider his call, prompted by Dr Atkinson's evidence, for the Baxter Patient Controlled Administration (PCA) device to be removed from hospital use. |
| Dosage | Dosage |
| Under questioning, Dr Atkinson conceded that no matter how many times the button on the device was pressed it would never administer no more than the prescribed dosage per hour. | Under questioning, Dr Atkinson conceded that no matter how many times the button on the device was pressed it would never administer no more than the prescribed dosage per hour. |
| Earlier on Tuesday, the Coroner's Court heard that the particular device used to give the mother-of-three morphine was thrown out after her death without being examined. | Earlier on Tuesday, the Coroner's Court heard that the particular device used to give the mother-of-three morphine was thrown out after her death without being examined. |
| The court heard it was therefore impossible to tell if it was faulty. | The court heard it was therefore impossible to tell if it was faulty. |
| Midwifery expert Fiona Summerville also told the second day of the inquest that no guidance existed at the hospital in relation to the devices or the need to preserve such items as potential evidence. | Midwifery expert Fiona Summerville also told the second day of the inquest that no guidance existed at the hospital in relation to the devices or the need to preserve such items as potential evidence. |
| Unexpected | Unexpected |
| However, Michael Lavery, QC, acting for the family, produced evidence of guidelines to be used in the event of an unexpected death. | However, Michael Lavery, QC, acting for the family, produced evidence of guidelines to be used in the event of an unexpected death. |
| Ms Summerville said those guidelines must not have been communicated to midwives by management at Antrim Area Hospital. | Ms Summerville said those guidelines must not have been communicated to midwives by management at Antrim Area Hospital. |
| The court heard that Ms Summerville and three other experts carried out an inquiry following the death. | The court heard that Ms Summerville and three other experts carried out an inquiry following the death. |
| She said they found no definite cause of death, but a high level of morphine in the blood was "the only abnormality". | She said they found no definite cause of death, but a high level of morphine in the blood was "the only abnormality". |
| "It was likely, but not certain, the death was caused by morphine," said Ms Summerville. | "It was likely, but not certain, the death was caused by morphine," said Ms Summerville. |
| The midwifery expert said no-one witnessed Mrs Brown dying but some snoring had been recorded prior to her death, possibly caused by respiratory obstruction. | The midwifery expert said no-one witnessed Mrs Brown dying but some snoring had been recorded prior to her death, possibly caused by respiratory obstruction. |
| She also said such deaths were "exceedingly rare". | She also said such deaths were "exceedingly rare". |
| Ms Summerville and her team made a number of recommendations to Antrim Area Hospital in the wake of Mrs Brown's death, including the creation of a midwifery risk management post. | Ms Summerville and her team made a number of recommendations to Antrim Area Hospital in the wake of Mrs Brown's death, including the creation of a midwifery risk management post. |
| Mr Lavery said he would have expected staff to know they should not dispose of equipment in the event of a death, in case it was required by police or a coroner. | Mr Lavery said he would have expected staff to know they should not dispose of equipment in the event of a death, in case it was required by police or a coroner. |
| The inquest continues in Belfast. | The inquest continues in Belfast. |