Pregnant woman died after artery was torn in surgery, inquiry finds

A report into the death of a pregnant woman in May has found there was a delay in spotting a tear of a main artery caused during surgery as well as further delays in managing the problem and resuscitation.

Malak Kuzbary Thawley of Brusna Cottages, Blackrock, Co Dublin died on May 8th 2016 at the National Maternity Hospital, Holles Street, Dublin.

Ms Thawley (35) died due to a tear in the abdominal aorta during the course of laparoscopic surgery for an ectopic pregnancy.

Ms Thawley, a teacher originally from Syria, was expecting her first baby. She was seven weeks pregnant when a scan identified an ectopic pregnancy.

A 239-page report of the hospital investigation into her death has identified three critical causal factors during the emergency surgery.

Among the report’s key findings were:

* There was an accidental tear of the aorta in the abdomen;

* There was a lack of experience in recognising and managing a vascular injury, during laparoscopic surgery, due to the rarity of the injury;

* Due to the rarity of the injury and recognition of how to manage it, there was a lack of clinical leadership and sub optimal communication between members of the medical team.

The report also said the lack of communication between the medical team resulted in untimely decision making and led to a delay in commencing surgery and resuscitation.

The hospital said, in the report, it was determined to ensure the recommendations would be implemented in a timely manner to improve the systems and processes in place for laparoscopic procedures and emergency clinical situations.

“The Coroner’s inquest is expected to begin soon and the facts of this tragic case will be examined there in public,” a spokesman for the hospital said.

“We are unable to comment and we have released no detail on this matter to any media outlet. Our thoughts are first and foremost with the family and friends of the woman who has died.”

Her husband, Alan Thawley told RTÉ the report into his wife’s death was “traumatising”.

“I remember walking with her to surgery and the nurses were telling me this is a very simple procedure and to relax. They told me it takes less than half an hour and that I’d be seeing her within 45 minutes, that everything would be OK and she would have a quick recovery,” he said.

“It wasn’t until about 20 minutes before she died that somebody came to tell me that she was probably going to die and I didn’t expect it at all.”

Mr Thawley said it was “difficult” to read the report into his wife’s death.

“I’m an absolute emotional mess and I’m trying to find a way to put one foot in front of the other. My pregnant wife, my best friend died... This perfectly healthy, beautiful woman just died suddenly out of nowhere, with no warning really.

“The report is almost talking about what happened like it’s a science experiment and I understand that this is what you need to do for these types of report but it’s so traumatising.

“I hate reading it and from my understanding, it looks like within the first 90 seconds or so, the aorta was cut and it immediately started bleeding. For whatever reason I can’t understand, it wasn’t found for a very long time.

“I’d say there’s probably five or six different areas where she could have been saved but each time they failed. I still don’t really know what happened. There are all these medical and technical details but I don’t actually know... why did she die?”