The inquest touching upon the death of baby Jaxon McVey
| Jurisdiction | Northern Ireland |
| Judge | Miss Dougan |
| Neutral Citation | [2022] NICoroner 11 |
| Date | 11 November 2022 |
| Court | Coroners Court (NI) |
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Neutral Citation No: [2022] NICoroner 11
Judgment: approved by the court for handing down
(subject to editorial corrections)*
Ref: 2022NICoroner11
Delivered: 11/11/2022
BEFORE THE CORONER OF NORTHERN IRELAND
BEFORE CORONER DOUGAN
THE INQUEST TOUCHING UPON THE DEATH OF
BABY JAXON MCVEY
Introduction
1. The inquest proceeded in hybrid form, meaning that a mix of remote technology
and live courtroom attendance was utilised. The case proceeded in Banbridge
Courthouse, between the dates of 24 and 28 October 2022. During the inquest, I
received evidence from a large number of witnesses, and I also considered a
number of statements admitted under Rule 17 of the Coroners (Practice and
Procedure) Rules (Northern Ireland) 1963(the 1963 Rules), allied with
voluminous guidelines, protocols and hospital notes and records. It is not
possible to recite all the evidence, although all the evidence has been considered
before arriving at these findings.
Inquest Evidence
2. The Deceased, Jaxon James McVey, was stillborn on 26 March 2017.
3. Miss Christine McCleery, mother of the Deceased, gave evidence to the inquest.
She previously had an uncomplicated birth with her first child in Lagan Valley
Hospital in 1999. On 25 July 2016, Miss McCleery attended her General
Practitioner Surgery, and her pregnancy was confirmed. A document named
“Essential Information for Antenatal Booking at Lagan Valley Hospital” was
completed by her General Practitioner, Dr Isabel Chu. This document recorded
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Miss McCleery’s weight as 81.6kg and her height as 155cm which resulted in a
Body Mass Index of 33.96kg/m2. Her estimated date of confinement was 27
March 2017. This document was forwarded to Lagan Valley Hospital
Freestanding Midwifery Led Unit. Miss McCleery told the inquest that Lagan
Valley was her first choice and that she was never given a reason to doubt that
choice.
4. Miss McCleery suffered from the usual symptoms in the early stages of
pregnancy, including sickness and reduction in appetite. The booking
appointment took place on 13 September 2016 when she was at 12 weeks
gestation. She was assessed by Staff Midwife Judith McIlwee in the Midwifery
Led Unit who deemed her suitable for midwifery led care. At the appointment,
the scan was conducted by Staff Midwife Claire McGuigan and Staff Midwife
McIlwee carried out the booking process. Miss McCleery was asked personal
details, health questions, family history and her bloods were taken. She was
then taken into a different room where her height and weight were measured.
Unknown to Miss McCleery at the time, Staff Midwife McIlwee documented
her height at 160cm. Miss McCleery recalled that the Midwife wrote the height
on a “scrap piece of paper” first and then transferred the figure into the
computer records. Miss McCleery stated that she was not wearing shoes when
her height was measured. She said she “never even thought to look at what she
(the midwife) had recorded down”. She told the inquest that the height of
155cm was the last recorded height taken by her GP and “I would have actually
given myself a little smaller than that if I am honest”. She went on to say her
height would be closer to 152.5cm rather than 160cm. Miss McCleery’s BMI was
calculated with reference to her height of 160cm, as 32.23kg/m2. As a
consequence of this calculation, she was advised that she fitted the criteria for
midwifery led care in the Midwifery Led Unit. Miss McCleery stated that later,
her personalised Antenatal GROW Chart for fetal measurement was plotted
based on this initial error of her maternal height being recorded as 160cm.
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5. At the booking appointment, Miss McCleery told the inquest that no risks of
birthing in the Midwifery Led Unit were discussed with her. She explained that
she is the kind of person, who, if “you talk about something with me and put
something in my head I will ask you a question about it”. She said there were
no discussions about risks.
6. Miss McCleery’s next appointment was the 20-week anomaly ultrasound on 9
November 2016. She was told that all appeared well and that the baby was
healthy. Both Miss McCleery and her partner Mr Martin McVey asked what
gender the baby was, and they were advised it was a boy; but that the result
was never 100% accurate. Her due date was given as 24 March 2017. She was
also told that as her body mass index was greater than 30 Kg/m2, a glucose
tolerance test would be necessary. The glucose tolerance test took place on 21st
December 2016 and the results came back as normal.
7. Miss McCleery continued to attend for antenatal care in the Lisburn Health
Centre until she reached approximately 36 weeks of her pregnancy. At that
point, care then transferred back to Midwifery Led Unit. The midwives from
the Midwifery Led Unit held a Clinic in the Health Centre every Tuesday.
8. Miss McCleery explained that the pregnancy was normal throughout, but her
pregnancy symptoms worsened with nausea and pressure. In terms of the
growth of the baby, the first measurement documented on the GROW chart (at
28+4 weeks) was in and around the middle line, the 50th centile. A midwife
explained to Miss McCleery that the middle line, where the deceased was
plotted, was the average. The top line represented a larger baby, and the
bottom line represented a smaller baby. This midwife explained that there
might be risks if the baby plotted below the bottom line or above the top line.
Miss McCleery described how the plot moved straight to the top line (the 90th
centile) on the next visit, which was at 30+4 weeks. Miss McCleery stated that
as the GROW chart was individual to her, it was incorrect, as it was based on
the measurement of her height at 160cm rather than her actual height.
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