Baby Cara Rocks inquest identified alarming failings
Inquests were not held into stillbirths in Northern Ireland until a landmark Court of Appeal ruling in November 2013.
The change came after Siobhan Desmond, whose son Axel was stillborn at Altnagelvin Hospital in Derry in 2001, campaigned for babies who died before birth to be given the same level of investigation as a child who died after drawing breath.
The appeal court's decision to allow coroners to hold inquests into stillbirths in Northern Ireland was highly significant and the importance of that ruling could be seen in recent days with the hearing into the death of baby Cara Rocks, who was stillborn at Causeway Hospital in Coleraine in June 2013.
Her parents, Barry and Michelle Rocks from Moneymore near Magherafelt, were present during this often distressing inquest and were praised by coroner Joe McCrisken for their fortitude and for ``fighting very hard for your baby.''
He said as a result of their actions in pursuing this inquest lives have already been saved.
This historic hearing provided ample justification for the appeal court's decision to hold hearings into stillbirths.
The number of failings that were identified in the care of Mrs Rocks during her pregnancy and labour must be regarded as deeply alarming.
In particular, the fact that she was refused an elective caesarean section despite repeated requests following difficulties in her previous two pregnancies, was a major issue in this case.
The Rocks family believe if a decision had been made for this procedure to be carried out at 39 weeks, baby Cara would be alive.
If nothing else, this harrowing inquest should ensure medics listen to women when it comes to the method of delivery. Women, too, should feel empowered to ask for a second opinion if their request is denied.
Mr McCrisken was critical of many aspects of Mrs Rocks' treatment and of individual staff in this case.
The Northern trust has now taken action aimed at avoiding similar tragedies and we must hope that baby Cara's death leads to real change.