A review of an investigation into the death of a 34-year-old woman at the National Maternity Hospital, Holles Street, has proposed that all maternal deaths be reviewed externally.
Malak Thawley was seven weeks' pregnant when she was diagnosed with an ectopic pregnancy. Unexpected bleeding was caused in an abdominal cavity during a procedure to treat her in theatre and she died on 8 May 2016.
Ms Thawley's widower, Alan Thawley, is due to meet Minister for Health Simon Harris in the coming weeks to discuss the terms of reference of an external, independent investigation into his wife's death.
Following Ms Thawley's death, the hospital conducted an internal investigation into the case and admitted liability.
However, the Department of Health requested a review of the investigation and established an expert panel to conduct it, independent of the hospital and the Ireland East Hospital Group.
The expert panel, led by Dr Peter McKenna who is Clinical Director of the National Women and Infants' Health Programme, proposes that all direct maternal deaths in Ireland be reviewed external to the hospital and Hospital Group where the death occurred, with guidance from the HSE National Women and Infants' Health Programme.
It recommends that NWIHP be notified of maternal deaths within 48 hours.
The NWIHP will establish a standing expert clinical panel to advise on the appropriate review approach to the report of a maternal death.
The panel concluded that given the nature of Ms Thawley's death, which was due to bleeding following trauma to an artery, the failure to include a vascular surgeon as a member of the Investigation Team was an omission.
The panel recognised that a vascular surgeon was part of the investigative process but not part of the complete review.
The panel's report states: "We are of the opinion that a vascular surgeon should have been part of the investigative team. This view is based on the extremely unfortunate nature of the case and also reflects the wishes of the deceased's husband."
