Mother (24) died as a result of medical misadventure, inquest finds

An inquest into the death of a woman who died on Christmas Day 2018, a week after giving birth, has found she died as a result of medical misadventure.

Karen McEvoy (24) developed post-natal sepsis in the days after the birth of her third child, Ruby, at the Coombe hospital on December 18th. She died at Naas General Hospital of multi-organ failure, secondary to puerperal sepsis, due to group A streptococcal infection, shortly before 4pm on December 25th.

The two-day inquest, held in Athy, Co Kildare, heard Ms McEvoy had been discharged home to Blessington, Co Wicklow, a day after her daughter was born and began feeling unwell, with flu-like symptoms and lower-back and abdominal pain, from December 20th.

Her partner, Barry Kelly, said she had attended a public health nurse (PHN) appointment in Naas on December 21st after which she had told him the nurse had said it was “normal” to have abdominal pain after giving birth.

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PHN Doreen O’Sullivan told the inquest she had not recorded any of Ms McEvoy’s vital signs as at the time she had no thermometer or sphygmomanometer (used to measure blood pressure).

On Friday the inquest heard Geraldine Kavanagh, midwife on duty in the emergency department (ED) at the Coombe on December 23rd, 2018, kept no record of her triage of Ms McEvoy. The inquest heard Ms McEvoy attended the ED in such pain that day she had needed crutches to walk.

Ms Kavanagh did not record Ms McEvoy’s vital signs, or refer her for medical assessment – in contravention of the hospital’s ED triage guidelines which had been in place since June 12th that year. She assessed that Ms McEvoy most probably had sciatica and advised her to attend St James’s or Tallaght hospital for an X-ray if the pain got worse.

Dr Peter Boylan, expert witness to the inquest, described this as a "regrettable" failure to adhere to the hospital's guidelines.

He also said it was “regrettable” that when Ms McEvoy arrived by ambulance to Naas hospital at noon on Christmas Day, in septic shock, that there was no consultant there. The inquest had heard on Thursday that Dr Rita Chaudry, consultant anaesthetist, arrived at the hospital at about 3.15pm, by which stage Ms McEvoy was in cardiac arrest.

Unanimous verdict

A jury of five men and two women delivered a unanimous verdict of medical misadventure and brought back 10 recommendations.

These included that a national leaflet on post-natal sepsis be provided to all mothers on discharge from maternity services and a health information campaign be conducted to increase awareness among the partners and families of mothers about post-natal sepsis.

The jury recommended PHN appointments with new mothers take place in mothers’ homes and that nurses have the necessary equipment, like thermometers; that post-natal PHNs and midwives be trained in recognition of sepsis, and that a consultant-led ED be in place when a critically ill patient with sepsis or in septic shock is en route to hospital.

The “most important” recommendation, the jury said, was that “all patients attending the emergency room of the Coombe hospital is assessed by a doctor”.

Kildare coroner Dr Denis Cusack would send the recommendations to the Minister for Health, Stephen Donnelly, and to the HSE, the Coombe and Naas hospitals, and the Institute of Obstetricians and Gynaecologists.

Save lives

Welcoming the verdict, Mr Kelly said he hoped the recommendations would save other women’s lives.

“Karen’s death was preventable. We always knew that but today we heard it,” he said. “She was an amazing mum, a brilliant lady and she will always be missed . . . She got her day today.”

He thanked his “amazing family” and legal team led by solicitor Niamh O’Brien of OBM Solicitors, without whom, he said, he could not have endured the last three years.

Ms McEvoy’s mother, Margaret McEvoy, said she hoped there would be increased awareness of sepsis. “Christmas will never be the same for us again.” What happened to her daughter was “so unfair”, she said.

Ms McEvoy’s father, Alan Kilbey, said he hoped nothing like it would happen to anyone else.