The death of a 38-year-old woman who died within hours of giving birth at Mayo General Hospital was as a result of medical misadventure, a jury at her inquest has found.
The jury made the finding yesterday on the fourth and final day of the adjourned inquest into the death of Evelyn Flanagan from Hollyhill, Castlebar. The mother of two died on October 19th, 2007.
Evidence was tendered to the inquest last September by Mrs Flanagan’s husband, Padraic Flanagan, that she had been perfectly healthy when she went into the hospital to be induced as she was 12 days overdue.
After several witnesses from the hospital including the hospital’s pathologist who carried out a postmortem examination on Mrs Flanagan were heard the inquest was adjourned to yesterday to obtain the views of two independent witnesses from the UK who had been retained by the coroner for south Mayo John O’Dwyer to review the dead woman’s medical records.
While the hospital’s pathologist Dr Fadel Bennani had said last year he was 100 per cent sure the maternal death was as a result of a rare event called an amniotic fluid embolism, which resulted from amniotic fluid which surrounded the baby in Mrs Flanagan’s womb entering her blood, ultimately causing a clot in her lung, UK pathologist Dr Kevin West presented a differing view at today's resumed hearing.
Dr West said he believed the cause of death was acute cardiac failure following post partum haemorrhage, following blood and fluid administration. He said amniotic fluid embolism couldn’t be ruled out as having a contributory factor but it was difficult to estimate its contribution.
Evidence was also given yesterday by Prof James Walker, chairman of the organisation responsible for confidential inquiries into maternal and neonatal death in the UK, that having reviewed Mrs Flanagan’s medical records he believed she was given eight units more blood than she required and this “fluid overload” could put pressure on her heart and could cause heart failure.
He said he could find nothing in the medical notes to indicate a full record was kept of all the fluids going in and out of the dead woman’s body when she was being transfused after she haemorrhaged following delivery. He found she was given 17 or 18 units of blood in all.
“She was transfused eight units of blood more than she had lost and eight litres of fluid more than she lost. This would lead to cardiac failure, pulmonary oedema, coagulation defects and an elevation of the potassium. All these factors could cause cardiac dysfunction and lead to cardiac arrest,” he said.
He added that even with the blood loss she suffered following birth due to a tear in her womb he would have expected her to have survived. "She appeared to die from cardiopulmonary failure secondary to fluid overload, cardiac dysfunction, pulmonary thrombosis and maybe amniotic fluid embolism.
“The exact timing of the occurrence of these events and the relative cause and effect of them is difficult to assess,” he added.
He agreed with John Jordan, counsel for Mr Flanagan, that she would have had “a better chance” if she was given the correct amount of blood and fluid.
The inquest also heard yesterday from Dr Irene Cheung, a junior doctor in anaesthesia at the hospital, who said while she asked a nurse to maintain a fluid balance chart for the patient – recording fluid input and output — none was kept.
“It should have been kept. There is no excuse for that,” she said.
Mr O’Dwyer told the jury they could return any one of three possible verdicts. These were death by natural causes, medical misadventure or a narrative verdict. After deliberating for less than half an hour the jury returned with their verdict of medical misadventure.
The coroner sympathised with Mr Flanagan and his two daughters on their loss. “This has been a difficult role for you to carry,” he told Mr Flanagan, before also sympathising with Dr Murtada Mohamed, Mrs Flanagan’s obstetrician, and other staff at Mayo General. “There is no winners here. It’s a tragedy that in the giving of life a lady dies,” he said.
Tony O’Connor, counsel for the hospital and the HSE, also offered his sympathies to the Flanagan family.
Mr Flanagan, on the first day of the inquest, last year said he believed if his wife had received proper care and attention at the hospital she would still be alive. He had claimed her blood loss wasn’t attended to as rapidly as it should have been.
But Dr Mohamed, who had been retained to treat his wife as a private patient, told the inquest when he gave evidence he would not have treated her differently if he had his time over. He said he believed she would still be alive were it not for the fact that she suffered an amniotic fluid embolism.