A High Court judge has awarded €170,000 damages to a woman whose baby was still-born due to the necessary blood not being available in an ambulance.
Fiona Ní Chonchubhair was bleeding internally and almost 32-weeks pregnant when she was sent on a two-hour 110km journey from Kerry General Hospital in Tralee to Cork Regional Hospital in 2009.
What had happened to Ms Ní Chonchubhair and her husband Stephen Cotter during this second pregnancy was “a disaster”, “the stuff of nightmares” and must be “burnt into their memories as an example of the most disastrous incompetence”, Mr Justice Sean Ryan said.
It was “scarcely credible in this day and age” an ambulance would be arranged and a patient suffering an internal bleed would be put in that ambulance without someone thinking of having the necessary cross-matched blood for transfusion, he said.
What had happened involved “bad decision making”, “extraordinary ineptitude” and a further delay when she arrived at hospital, he said. It was accepted by the HSE this led to “a dreadful tragedy whereby the couple’s baby died".
The judge said he must award damages on the basis of legal principles, not on the basis of expressing human sympathy or his sense of indignation this had happened. He assessed damages in a total sum of €170,000 for Ms Ní Chonchubhair against the HSE.
In her action, Ms Ní Chonchubhair (36), Countess Road, Killarney, Co Kerry, sued for severe personal injuries and shock due to negligence and breach of duty arising from the still-birth of her son Aodh.
Ms Ní Chonchubhair was sent by ambulance from Kerry General Hospital in Tralee on a 110km journey to Cork Regional Hospital. When the ambulance arrived at CRH, it took another 15 to 20 minutes for the crew to locate the accident and emergency unit, the court heard.
Ms Ní Chonchubhair was operated on and received six units of blood to replace what she had lost but the transfusion was too late for her baby who was delivered still-born by emergency cesarean section on May 16th, 2009.
Had she received a transfusion en route, she would have suffered a less severe level of hypovolemic shock which had resulted in the baby not getting enough oxygen, her counsel Eugene Gleeson SC said.
Emily Egan SC, for the HSE, had at the outset of the case offered an apology for what had happened to the couple. Liability was admitted and the case was before the judge for assessment of damages only.
Mr Justice Ryan said it was unnecessary to dwell in detail on what happened to this unfortunate couple. He said Mr Cotter had described matters well, that before this happened, things were going so well for himself and his wife as they had one little boy and she was pregnant a second time.
The couple, a dentist and orthodontist, were themselves medical experts and had every reason to believe Ms Ni Chonchubhair was in exactly the right place, a hospital, when she experienced difficulties traced back to another operation in England, he said.
He noted Ms Ní Chonchubhair felt they were ignored and treated with some degree of indifference in the Tralee hospital.
He said he wanted to concentrate on the serious questions, that there was a lengthy transfer to Cork Regional Hospital when there should not have been. It was “scarcely credible” in this day and age an ambulance would be arranged and a patient suffering from internal bleed would be put into that without someone thinking of having the necessary cross-matched blood for transfusion.
It was also clear from Mr Cotter’s evidence the ambulance managed to take some slow route from Tralee to Cork to arrive after him although he had headed home as his wife was about to leave Tralee, the judge said.
In fairness, the judge added, the HSE had apologised, there was a clear admission of responsibility and that should make some difference. He added one could speculate “as to what might be a useful follow up”, whether to ask a person to come to hospital and help avoid this in the future.
He found Ms Ní Chonchubhair had experienced elements of post-traumatic stress disorder, severe bereavement disorder and adjustment disorder. Since this tragedy, Ms Ní Chonchubhair had suffered flashbacks and intrusive recollections, he said. She had also experienced, not just anger but a raw visceral rage.
On the positive side, the couple had been blessed with two other children since, the judge added.
When the case opened, the judge was told the HSE had carried out an internal review of what happened to Ms Ní Chonchubhair and had made 12 recommendations to ensure it would not recur. Ms Ní Chonchubhair, now a full-time mother of three expecting her fourth child, told the judge she had no confidence the recommendations would be followed.