The jury at the inquest into a maternal death at University Hospital Kerry in April 2022 has returned an unanimous verdict of medical misadventure.
Mother-of-three Tatenda Mukwata, 34, died after giving birth to her fourth child.
The jury found she died at the hospital in Tralee on 21 April 2022.
"This was probably preventable. There was a misdiagnoses followed by a failure to investigate other possible differential misdiagnoses," the jury said in its findings.
The cause was a catastrophic bleed haemorrhage and shock due to uterine arterial malformation following a Caesarian section.
The Tralee jury made seven recommendations including:
- Clinicians need to heed nurses' concerns
- Investigate all likely causes of diagnoses
- Staff should not be required to work excessive hours on health and safety grounds
- Establish an emergency response team in the maternity unit with proper training and education on haemhorrage policies
- Review laboratory communication procedure
- Review efficiency
It also recommended that "an electronic record system be brought back in all sections in UHK, the Southwest Hospital Group and HSE network with appropriate cyber network protection".
Routine early post-partum blood tests for haemoglobin should also be introduced.
Evidence
Earlier, Dr Mary McCaffrey, who was the consultant obstetrician responsible for the care of women in labour at the hospital in April 2022, gave evidence to the inquest.
She had seen Ms Mukwata at 5pm and examined her. Her risk factors included being HIV positive, as well as high blood pressure.
The on-call registrar Dr Fahad Hendricks and two nurses in post-operative care suspected sepsis was setting in.
Dr McCaffrey asked about the possibility of bleeding and was told there was no obvious sign of bleeding. Dr Hendricks too was "absolutely confident" there was no bleeding.
At 9.15pm, Dr McCaffrey requested the bloods, but was told they were not done.
"I was taken aback because I assumed the sepsis protocol had kicked in," she said. She ordered this to be done.
Had the bloods been done in a timely manner, and the results back quickly from the lab, in accordance with the national protocol on sepsis, the hemorrhaging would have been detected, she said.
The staff nurse had concerns at that stage it was sepsis, she said.
"This was understandable, as sepsis had been a focus by everyone since the death of Savita Halappanavar," she said.
At no stage did a nurse ring her directly, as they "not infrequently" did during her 25 years at UHK, to elevate their later concerns about bleeding, rather than sepsis, she said.
Had the bleeding been recognised, it would still have been quite a complicated surgery, Dr McCaffrey added when replying to Dr O’Mahony, counsel for the Mukwatas.
"We would have done the surgery, but people have to understand, it wouldn't have been simple, " said Dr McCaffrey, who is now retired from UHK.
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