THE DEATH of a 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 (38) from Hollyhill, Castlebar. The mother of two died on October 19th, 2007.
Evidence was given to the inquest last September by Ms Flanagan’s husband Pádraic Flanagan that she had been perfectly healthy when she went into the hospital to be induced as she was 12 days overdue. 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 Ms Flanagan’s womb entering her blood, ultimately causing a clot in her lung, UK pathologist Dr Kevin West presented a differing view at yesterday’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 being 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 Ms Flanagan’s medical records, he believed she was given eight units more blood than she required and this “fluid overload” could have put pressure on her heart and could have caused 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 her 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,” she said. “There is no excuse for that.”