Woman discharged after giving birth ‘without adequate assessment’

A woman who became unwell while giving birth at Cavan General Hospital and was subsequently diagnosed with septicaemia at a different hospital has received an apology from a HSE review team looking into her treatment.

Grace Vaughan was pregnant with her second child in March, 2013 when she encountered severe medical difficulties. After giving birth, she left hospital in a wheelchair, unable to walk due to pain.

In a report completed by the HSE last June, but previously unpublished, her review team added their apology to those previously extended by the director general of the HSE and the hospital’s general manager.

The report from the review team which has been seen by The Irish Times found she had been discharged after the birth of her child "without adequate assessment".

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Hours after returning home, Ms Vaughan was rushed by ambulance to Our Lady of Lourdes Hospital in Drogheda where she was diagnosed with septicaemia, severe blood poisoning.

Outlining the series of events, the HSE report noted Ms Vaughan had attended Cavan General Hospital on March 1st, 2013, complaining of headaches and visual disturbances. She recalled telling a midwife she had had difficulty walking but being told a consultant was unavailable.

The following day she told nurses she had not slept in days due to pain. “[She] recalls that she was not seen by the on call consultant on that day either and this distressed her, to the point that her husband suggested that they go to another maternity hospital,” the review stated.

Having been advised she could not see a consultant until the following Monday, Ms Vaughan decided to go home.

However, she returned the following night and was readmitted. Two days later she reported feeling shivery and later, while in labour in the early hours of March 6th, experienced “terrible pain” and believed her epidural had been turned off.

Just before 4am, the obstetric registrar was informed about delayed progress in the second stage of delivery. “[Ms Vaughan] recalls that doctor present was very blasé in the responses to her about the duration of the delivery and the pain being endured,” the report said.

A vacuum was applied at 4.05am and five minutes later her baby Charlie was delivered. Again, Ms Vaughan had asked the midwife why the epidural was not turned on but did not receive an answer, the report said.

Short staffed

In the early hours of the following morning Ms Vaughan woke up and reported feeling very sweaty. Later she experienced severe pain and recalled her husband getting a wheelchair to bring her to the bathroom.

Her pain continued into the next day and she “recalled one of the midwives feeding her baby as she was too sore to undertake the task herself”.

Later on she remembered being told “the ward was short staffed and she would need to contact her husband to help feed and change her baby”, the report said.

At 2.30pm on Friday, March 8th, Ms Vaughan was discharged from hospital but needed a wheelchair to get to her car. She recalled, the report noted, the porter commenting on her leaving given the condition she was in.

At about 10.30pm, Mr Vaughan called an ambulance for his wife who was rushed to Our Lady of Lourdes Hospital where she was later diagnosed with septicaemia.

As part of a subsequent complaint over her care, Ms Vaughan also raised problems in contacting medical staff at Cavan General Hospital following her discharge.

“It is clear to the review team,” the report stated, “that the ineffective communication process in 2013 was the cause of considerable levels of distress to the family.”

Despite the seriousness of her case, the report from the review team found Ms Vaughan’s experiences were at times “in contrast” to the recollections of the clinical staff involved in her care.

“Due to the passing of time, the staff recollections are vague or non-existent,” it said.

Despite this, the review team found the patient had been discharged after the birth of her child “without adequate assessment”.