A verdict of death by misadventure has been returned following the death of a woman at the Rotunda Hospital in Dublin. The City Coroner, Dr Brian Farrell, returned the verdict at the Coroner's Court in Dublin yesterday.
Mrs Swarnili Basu (30) died at the maternity hospital on January 7th this year after the delivery of her son, Jim, by Caesarean section the previous day.
Following the delivery, Mrs Basu experienced 13 hours of intractable bleeding. She underwent a hysterectomy and suffered three cardiac arrests before dying early on January 7th.
Dr Nilajum Basu, of Ardmore Drive, Dublin, said that his wife was admitted to the Rotunda on December 9th, 1998, two weeks before the expected birth of their second child. Her placenta was blocking the cervix - a potentially serious condition known as placenta previa, meaning that the baby could not be delivered naturally and that the final weeks of the pregnancy would require monitoring. The placenta had also begun to invade the uterine wall.
Although initially under the care of a team of doctors, Mrs Basu came under the care of Ms Carol Barry-Kinsella, a consultant in obstetrics and gynaecology, on the day of delivery.
Ms Barry-Kinsella told the court that an elective Caesarean section was carried out by Dr Michael Geary, a senior registrar, at 1.45 p.m. on January 6th. Due to the position of the placenta, Dr Geary cut through it to get to the baby. Ms Barry-Kinsella said that she was not present during the delivery, although she was "scrubbing in". A healthy baby boy was delivered at 1.53 p.m.
Dr Geary said that he removed the placenta in a "piecemeal" fashion because it was adhering to the uterus. "There was evidence of placental bleeding", he said, "although it was not torrential." When the placenta was fully removed, he closed the uterus and abdomen. Mrs Basu was taken to a recovery room at 2.25 p.m.
Ms Barry-Kinsella had left the hospital and Dr Geary left the theatre before Mrs Basu was taken to a recovery room. He said he was satisfied that Mrs Basu was stable. Between 2.40 p.m. and 3.50 p.m. Mrs Basu's blood pressure fell continuously and on four occasions was found to be "unrecordable", according to the hospital's records. She also lost over two litres of blood during that time.
Dr Geary said that transfusions were carried out while attempts were being made to stem the bleeding. Mrs Basu was returned to the theatre at 3.50 p.m. He called on a senior consultant, Mr Malachy Coughlan, to assist him at 3.40 p.m., and further attempts were made to stem the bleeding. Mrs Basu's abdomen and uterus were reopened and the bleeding was found to stem from the site of the placenta's adherence to the uterine wall. It was brought under control.
However, while her abdomen was being closed, at 6.30 p.m. Mrs Basu suffered two cardiac arrests and pulmonary heart massage was administered. Further bleeding occurred, by which stage Dr Geary and Mr Coughlan had been rejoined by Ms Barry-Kinsella and joined by Mr William Hickey, a former senior consultant.
Mrs Basu's abdomen was reopened and, as the bleeding could not be stopped, Mr Coughlan said, he decided to carry out a hysterectomy. This was done between 9.30 p.m. and 10 p.m.
Mr Coughlan told the court that the oozing of blood continued nonetheless.
The Master of the Rotunda, Dr Peter McKenna, said he was contacted at 9.30 p.m. and arrived at the hospital at about 11 p.m. He found that Mrs Basu's situation was "not critical but of considerable concern".
Mr Coughlan said that after a time they had felt they were "in control of the situation". However, Mrs Basu experienced a third cardiac arrest at 2.01 a.m. on January 7th. Despite pulmonary heart massage for half an hour, they were unable to resuscitate her.
Dr John Gillan, director of pathology at the Rotunda, said Mrs Basu died of hypoxic-ischaemia, or lack of oxygen to her vital organs, and cardiac arrest. He said hypoxic-ischaemia had begun in the afternoon.
After the verdict Mr McKenna described the events of January 6th-7th as a "terribly tragic day for everyone" and extended his condolences to the Basu family.
Mr Basu said that he would be discussing the verdict with his legal advisers.
