An independent inquiry into the death of a 32-year-old woman following IVF treatment at Dublin's Rotunda hospital has identified problems with the management of her care in the hospital.
The report of the inquiry team published yesterday by the family of the late Jacqui Rushton, of Ardleigh Park, Mullingar, Co Westmeath, said there was "evidence of lack of senior control over, and overall accountability" for her care at the Rotunda.
It found "appropriate and early management" of fluids in her system would have prevented her subsequently developing severe respiratory problems, which led to her death.
Mrs Rushton, a hospital clerical worker who had been married for over three years and was longing to have a child, had undergone fertility treatment at the Human Assisted Reproduction Ireland (Hari) unit attached to the Rotunda hospital during November and December 2002. She was given a drug to stimulate her ovaries to produce eggs. She reacted to the treatment, developing ovarian hyperstimulation syndrome (OHSS). She was admitted to the Rotunda hospital on December 8th 2002 and transferred to the Mater hospital on December 16th, 2002, where she died on January 14th, 2003.
The inquiry found she received great care at the Mater but there was inconsistent compliance with Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for OHSS treatment at the Rotunda. "The clinical features of OHSS, in particular those related to fluid balance changes, were recorded in the notes but some appropriate actions were not always taken," it said.
An inquest in 2004 found Mrs Rushton died of adult respiratory distress syndrome arising as a complication of OHSS. The coroner returned a verdict of medical misadventure.
After the inquest Mrs Rushton's parents Angela and Fintan Hickey, her husband Danny and her seven siblings asked the Minister for Health to set up an inquiry. The HSE commissioned two UK experts to carry it out.
Angela Hickey said their report was a clear indictment of the standard of medical care received by Jacqui at the Rotunda. "It is clearly the view of the authors of this report that had Jacqui been better managed and if the appropriate medical procedures and protocols been adopted, the likelihood is that she would be with us today. Instead the treatment she received only exacerbated the build-up of fluid in her abdomen and paracentesis, a procedure used to drain fluid from the abdomen, was never performed," she said.
She added that her family's journey to find the truth in relation to what happened to Jacqui had been a difficult one. They were met with a veil of silence by the medical profession and felt unable to voice their opinion during a Medical Council fitness to practise inquiry into the Hari unit's director, Prof Robert Harrison. That inquiry found he had no case to answer.
The family has now decided to drop legal proceedings against the hospital, saying it only wanted the truth, not compensation, and this report provided it.
The report recommended the in-house protocol for management of OHSS at the Rotunda should be reviewed in the light of new guidelines in 2006. It also said this protocol should be regularly reviewed and its implementation regularly audited.
Welcoming the report, the master of the Rotunda Dr Michael Geary, said: "There has been a clear and strong desire to learn from the experience and to ensure that a similar event does not happen again."But he said while the report suggested there was evidence of lack of senior control over Mrs Rushton's care she was seen on a daily basis by experienced medical staff.