THE HEALTH SERVICE Executive (HSE) has launched a review into the death of a woman in her 30s one day after losing her baby.
The incident was first reported on in the Irish Independent, who said it is is understood that the woman was admitted to University Maternity Hospital Limerick on Thursday, 15 February, after feeling unwell.
On Saturday, 17 February, the paper reports that the woman was then informed she had lost her baby and the next day, 18 February, her condition deteriorated rapidly and she died.
Maternal deaths in Ireland are rare and a report for the years 2019 to 2021 found that there were 12 maternal deaths during this period.
The Confidential Maternal Death Enquiry in Ireland Report for 2019–2021 found that six of these deaths which were classified as being direct maternal deaths (due to obstetric causes).
Five were indirect maternal deaths (due to pre-existing disease aggravated by pregnancy), and the remaining one was attributed to a coincidental cause (not due to direct or indirect causes).
Responding to media queries about the sudden death of a woman in her 30s at UHL last Sunday, 18 February, the University Limerick Hospital Group said it was “currently reviewing the circumstances” surrounding the patient’s death “as is normal HSE practice where a sudden death occurs in our care”.
It added that this review “will inform any future actions”, and our staff continue to be available to support the family through this difficult process”
The HSE also asked today that persons commenting on “recent incidents and deaths” of patients at the University Hospital Limerick (UHL), do “not jump to conclusions” as to the nature and outcome of the cases.
The HSE statement came in the wake of publicity surrounding the deaths at UHL of the woman in her 30s last weekend, and the deaths of two female teenagers at the hospital last January and last December.
The hospital, which has the only emergency department in the mid-west region, taking patients from across Limerick City and County, Clare, north Tipperary and parts of north Cork and north Kerry, is persistently the most overcrowded hospital in the country.
Advocates for families of UHL deceased patients have repeatedly called on the government to reverse a decison made in 2009 to reopen 24-hour A+E units in Clare and north Tipperary to try to alleviate overcrowding at UHL however the government have said it has relied on clinical advice in making its decison.
Responding today to a request for comment on the death of a women in her 30s at UHL last Sunday, one day after losing her baby, the HSE replied: “We would ask that in relation to recent cases at UHL, as in any unexplained death in any hospital, that commentators not jump to conclusion and to respect the dignity of those who have died, the privacy of their grieving families and the dedication of our staff who come to work each day in the spirit of professionalism and care.
“We have excellent front line staff across our services including Limerick,” it said.
The beginning of the HSE statement read: “Our first thoughts in relation to patient deaths at any location are with those affected.
“However we are concerned that some current commentary in relation to tragic outcomes at University Hospital Limerick is putting forward inappropriate conclusions about some of these cases, and could affect the confidence of people in attending the hospital.
“We always address legitimate concern and questions, and have done so recently in the Mid West.
“However not every tragic outcome for a family in Limerick means there has been a failure in the service. Not every tragic outcome has the same attributes as other cases in which failure has been identified.”
Quoting HSE chief executive Bernard Gloster, the statement continued: “We have robust mechanisms for inquiring into unexpected deaths, unexplained poor outcomes and complaints, and we use them very regularly.”
“In Limerick, as with all our hospitals and services, we have an Incident Framework. When examining a concerning outcome we do not start from a conclusion. We assess the evidence, and then draw conclusions,” Golster said.
“The primary aim is first to establish what happened and how, and then to take any appropriate actions.
“Most such reviews, no matter what the outcome, give us the opportunity to learn how to improve for other patients and service users.
“I have mandated a questioning environment in the interests of patient safety which I believe our staff accept as the norm,” he added.
The statement went on: “In relation to recent deaths and cases in UHL, each case is looked at in its own right. Two cases are rarely the same. Similarities such as patient age for example, do not suggest the cases are the same.
“The public can be assured of our full attention to each case. All cases are considered in our incident frameworks, and in the case of maternal death there are very specific national processes followed regardless of the cause of death.
“We base our conclusions on systems analysis reviews, coroners courts and, if the evidence suggests, further appropriate inquiry.
“Scrutiny and robust questioning will be copperfastened further in the new HSE structures when a revised national patient safety unit with a replica unit in each of our six Regions are established.
“All will operate on the basis of ensuring several layers of analysis and questioning to give the greatest level of assurance.”
A HSE review of the death of 16-year old Aoife Johnston, from Shannon Co Clare, at UHL on 19 December, 2022 found she died from sepsis after developing complications from bacterial meningitis after she had waited on a trolley for 12 hours in the hospital’s severely overcrowded emergency department.
The review of Ms Johnston’s care at UHL has led to an independent investigation to her death by former Chief Justice Frank Clarke which has yet to be concluded.
Following the sudden death off another 16-year old girl at UHL on 29 January last, the ULHG expressed its “score condolences” to the girl’s family and said it had carried out “a preliminary assessment” into the girl’s death, “in line with the HSE Incident Management Framework, our normal practice where a sudden death occurs in our care”.
It added that “the findings from this assessment will be shared with the family pending the results of a post-mortem examination”.
The hospital group said that it was “in direct contact with the family on these matters and it would be inappropriate to comment further”.
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