AN INQUIRY into the death of a 34-year-old woman after she gave birth to twins at Our Lady of Lourdes Hospital in Drogheda just over a year ago, has found doctors at the hospital did not diagnose that her waters had broken when she presented to the hospital a few days before giving birth. EITHNE DONNELLAN, Health Correspondent reports
The report of the investigation into the death of Tania McCabe says she presented at the hospital on March 6th, 2007, believing her waters were breaking. However, her consultant believed she had "an episode of urinary incontinence rather than a rupture of membranes".
She was kept in overnight and the following morning, a midwife noted she believed the woman's waters had broken. This information does not seem to have found its way to the consultant who decided to discharge her and review her condition on March 9th, by which time she was dead.
The report, seen by The Irish Times, says: "Gaps in communication and an over-reliance on tests contributed to missing the diagnosis . . . It is unlikely Tania would have been discharged home if ruptured membranes had been diagnosed."
The report notes Mrs McCabe had a urinary tract infection at the time of her initial presentation. When she returned to the hospital on March 8th, sepsis had set in. But, it says, "the early warning signs of impending collapse largely went unrecognised".
In addition, it states short-staffing at the hospital
compromised the care given to Mrs McCabe. It said the maternity,
paediatric and anaesthetic services were significantly
under-resourced and "despite the
good intentions of staff who were working in very difficult
conditions, their practice and ultimately the care that they
provided to Tania were compromised by their workload and the
environment in which they were working".
The report identifies shortcomings in record-keeping.
The inquiry team, established by the Health Service Executive
(HSE), found "that it was a system failure
that led to Tania's death". No staff members are named in the
report. Mrs McCabe, who was less than
seven months pregnant, had an emergency Caesarean section on
March 8th and twins were delivered.
One died shortly afterwards. The other survived.
The report concluded Mrs McCabe died from sepsis "with haemorrhage as a complicating factor" and that her son's death "was an inevitable consequence of his congenital abnormalities".
Staff at the Lourdes hospital have been briefed on the report, which makes 27 recommendations. A copy was sent to the dead woman's family. Michael Boylan, solicitor for the family, last night questioned whether the antibiotics prescribed for Mrs McCabe's urinary tract infection when she first presented to the hospital were adequate.
The HSE said it will move quickly to look at the recommendations and how best to approach their implementation.