A coroner has returned a verdict of medical misadventure at an inquest into the death of a 28-year-old biopharmacist who had been living in Ballyhaunis and died at Mayo University Hospital (MUH) last October hours after she gave birth to a healthy infant girl.
Delivering the judgement this afternoon at Swinford Courthouse, the Coroner for Mayo, Pat O’Connor said there were a number of factors that led to the death of Nayyab Tariq on March 22, 2020.
The most significant factor, the coroner noted, appears to have been a concealed haemorrhage which did not become obvious despite monitoring of her vital medical signs.
Mr. O’Connor said that despite having a post-partum measured blood loss of approximately 500mls Nayyab did not seem to have any significant difficulties whilst in the labour ward.
However, her blood pressure remained low whilst her heart rate was high and she experienced nausea.
The coroner also noted the clinical medical findings in the Labour Ward were not fully communicated to the Theatre staff.
He said that on transfer to the operating theatre – for the removal of the placenta – there were clinical signs of tachycardia, hypotension and an increased respiratory rate.
The coroner added that Nayyab had a general anaesthetic in the theatre which made physical observations of her condition more difficult.
Nayyab had a manual removal of the placenta and suffered a cardiac arrest. Despite efforts to resuscitate her she died.
The coroner made a recommendation to MUH and the Saolta Group that all the findings and recommendations made by Professor John Morrison and the Review Group chaired by Dr. Carmen under the title of Systems Analysis Review Report (Feb 2021) be actively followed and implemented.
Mr. O’Connor expressed sympathy with the family of the deceased and the staff of MUH, particularly those who cared for Nayyab who all suffered a great deal from the sad passing.
Conor Halpin, senior counsel, read a statement on behalf of Catherine Donohoe, Manager of MUH, in which she expressed sympathy with the bereaved family and stated she was “truly sorry” for what happened and hoped that lessons would be learned.
Consultant pathologist Dr. Fadel Bennani gave evidence that Hayyab died tragically in rare and unexpected circumstances a few hours after an uncomplicated vaginal delivery of a healthy baby.
The placenta was retained in uterus which was manually removed under general anaesthetic and described as a straightforward procedure.
The deceased, Dr. Bennani said, she developed a significant intra-peritoneal pelvic haemorrhagic with no identifiable source of bleed at laparotomy.
A subtotal hysterectomy was performed after temporary short recovery from fatal ventricular fibrillation.
Dr. Bennani said the cause of death in his opinion was multifactorial.