THE DEATH OF a young mother who died a week after giving birth to her third child following an uncomplicated pregnancy was due to medical error, an inquest has found.
A jury returned a verdict of medical misadventure for the maternal death of Karen McEvoy (24) of Red Bog, Blessington, Co Wicklow who suffered a fatal cardiac arrest at Naas General Hospital on Christmas Day, 2018 from multiple-organ failure as a result of sepsis.
Ms McEvoy, who comes originally from Tallaght, Co Dublin, had given birth to a daughter, Ruby, at the Coombe Women and Infants University Hospital in Dublin on 18 December 2018 before suffering progressive pain over the following days after she returned home.
Former Master of the National Maternity Hospital, Peter Boylan, who appeared as an expert witness, told the inquest that the failure of the Coombe to check Ms McEvoy’s vital signs when she attended its emergency room on 23 December 2018 was a missed opportunity.
Evidence had been heard during the two-day inquest at Kildare Coroner’s Court that Ms McEvoy and her partner, Barry Kelly, were informed the pain she was suffering was due to sciatica and advised to go to an adult hospital if the pain was still continuing after two days.
Prof Boylan said it was “regrettable” that guidelines which had been in place since 2006 had not been followed during Ms McEvoy’s visit to the Coombe.
In addition to the failure to check vital signs, he pointed out no records of the examination were available and there were no results for a urine sample that had been provided by the patient.
Prof Boylan said it was likely a more detailed assessment of the patient would have allowed medical staff to detect an abnormality with Ms McEvoy which would have enabled them to diagnose an infection.
However, he conceded that it was not possible to say definitively if such an abnormality would have been detected.
Prof Boylan said the early detection of sepsis was “challenging” for medical staff and he acknowledged that the rarity of maternal deaths from sepsis meant there was a low awareness of such cases among doctors and nurses.
He said an examination of medical records and witness statements showed Ms McEvoy had displayed symptoms consistent with a developing inflammation by December 22, 2018.
“If Ms McEvoy had intense treatment from 24 December 2018, the outcome might have been different,” he observed.
The retired consultant obstetrician also expressed concern that no consultant had been on site at the emergency department in Naas General Hospital until around the time Ms McEvoy suffered a fatal cardiac arrest during treatment over two hours after she had been brought there by ambulance.
Prof Boylan said such a situation was “regrettable” and he had “a major problem” with such a scenario.
Prof Boylan said Ms McEvoy was seriously ill by the time she was brought to Naas General Hospital on 25 December 2018 but it was “debatable” whether the outcome would have been different if she had been brought to St James’s Hospital in Dublin, which was being considered by medical staff, as he believed her condition was “basically unsalvageable” at that stage.
The inquest heard maternal deaths from sepsis arise in one in every 100,000 pregnant women while the infection, which causes an extreme reaction in the body, is fatal in 60% of cases of septic shock.
At the conclusion of what the coroner, Professor Denis Cusack, described as “a case of national importance,” the jury of two women and five men issued ten recommendations including ones calling for campaigns and training to raise awareness about maternal sepsis among the public and medical staff and to ensure all patients were seen by a doctor before leaving the Coombe.
It also recommended that public health nurses should have equipment to check the vital signs of new mothers during home visits after the inquest heard such equipment was not available to a nurse who examined Ms McEvoy on 21 December 2018.
Prof Cusack said he hoped the recommendations on what was “a tragic maternal death” would prevent further fatalities in similar circumstances.
He said the recommendations would be notified to the Minister for Health, the HSE and the two hospitals as well as the Royal College of Physicians of Ireland.
Last November, the Coombe apologised over “failings in care” of Ms McEvoy as part of a confidential High Court settlement in an action taken by Mr Kelly and the couple’s three children – Jake (7), Toby (5) and Ruby (3).
At the end of the inquest, an apology was again read out on behalf of the Master of the Coombe, Professor Michael O’Connell, who said the hospital “fully accepts these failings should not have happened.”
Speaking after the hearing, Mr Kelly said he was very happy with the verdict and expressed hope that the recommendations could save other women’s lives.
“Karen’s death was preventable. We always knew that but today we heard it,” he added.
Karen’s parents Margaret McEvoy and Alan Gilbey also expressed satisfaction with the verdict.
“It’s been a really horrendous three years and a tough two days. I hope there is a lot of awareness put out there about sepsis as I don’t want my daughter’s name to be forgotten,” said Ms McEvoy.
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