AN INQUEST into the death of a woman who died after giving birth to twins at Our Lady of Lourdes Hospital in Drogheda heard yesterday how she was discharged from the hospital two days before she died, even though there appeared to be confusion over whether her waters had broken.
A verdict of medical misadventrue was returned at Louth Coroner's Court. The inquest heard that Tania McCabe (34) telephoned her husband on March 6th, 2007, saying her waters had broken while she was at work at Santry Garda station in Dublin.
Her husband Aidan McCabe told coroner Ronan Maguire that when he took over driving her to the hospital he noticed the car seat was very wet and suspected her waters had indeed broken.
At the hospital, an ultrasound was performed by obstetrician Dr Shane Higgins which appeared to show there was still fluid around the twins in her womb. An amnisure was then carried out to see if her waters had broken. The test came back negative.
However she was kept in overnight so the tests could be done again next morning. Overnight a bad kidney infection was diagnosed and she was put on antibiotics.
Mr McCabe said the next morning, March 7th, he got a text message from Tania saying a midwife with more than 20 years experience who examined her was sure her waters had broken. He went immediately to the hospital. When he arrived, two tests were again being performed to see if her waters had broken.
A midwife said one of the tests was positive and the other negative, but a junior doctor was emphatic both were negative. His wife was discharged home and told to relax.
The following day, March 8th, Mr McCabe said his wife had pains in her lower abdomen and remained in bed most of the day.
In the evening they became concerned and returned to the hospital. When Dr Higgins examined her she was 5cm dilated and was told she would have an immediate Caesarean section.
Her twins, Adam and Zach, who were not due until June, were born shortly after 9pm. Dr Higgins told Mr McCabe that Tania and Adam were fine but Zach wouldn't make it. While in the neonatal ward with their twins, Zach died and Mr McCabe said he noticed a lot of blood underneath Tania on the bed.
In the early hours of the morning he said Tania became agitated and restless. She was taken to intensive care, Dr Higgins was called in and at about 4am, Dr Higgins explained he would take Tania to theatre to try to stop the bleeding and he might have to do a hysterectomy. At about 6am, Dr Higgins came out of theatre and told him Tania had died.
"I simply could not take in what I was being told as I was so shocked and distressed," he said.
Dr Michael Curtis, the Deputy State Pathologist, said his postmortem found the lining of Tania's womb inflamed. He concluded that she died of multi-organ failure and post-partum haemorrhage due to sepsis as a result of E.coli and said an ascending infection due to this would have caused chorio-amnionitis (inflammation of the membranes surrounding the babies in the womb).
The coroner said there was only one verdict he could return in this case and that was medical misadventure. He said the HSE's review of Ms McCabe's case found that her ruptured membranes were not diagnosed when she first presented to hospital, and that septic shock was not diagnosed when she presented the second time.
The review found her death was as a result of a catastrophic systems failure, Mr Maguire added.
"I want to say this has been one of the most appalling tragedies I've come across as a coroner. This was a horror that was visited on this family . . . it shouldn't have happened".
He said advances in medicine had made maternal death very rare but a systems failure at the hospital had led to death. This had been recognised by the hospital and he was now strongly urging both the HSE and the hospital that the recommendations of the review group in this case be implemented urgently.
Mr McCabe said in evidence his foremost concern was that the recommendations be implemented so that what happened to Ms McCabe would not happen to anyone else. He added that their first child, Ben, was born with no difficulties in 2004.
Mr Maguire returned an open verdict in the case of the death of baby Zach. Dr Marie Staunton, the hospital's histopathologist, gave evidence the baby had developed a pneumonia in the womb. She said he was extremely premature and had a congenital abnormality.