An inquest into the death of a woman who died after giving birth to her son at home has returned a verdict of medical misadventure.
Laura Liston died on June 5th, 2022 after giving birth to her first child in Croom, Co Limerick under the HSE home birth services.
After she gave birth to a healthy baby boy, she experienced complications when trying to deliver the placenta.
She was transferred to University Hospital Limerick (UHL) by ambulance where she died from hemorrhage and shock due to uterine inversion, which is a rare but life-threatening complication of child birth.
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Delivering his verdict in Kilmallock courthouse in Co Limerick on Wednesday, coroner John McNamara said the couple were about to “embark on a very exciting part of their lives”.
He expressed his condolences to the family for the “immeasurable loss you have suffered”.
In a statement read outside court by their solicitor, Scarlett Griffin O’Sullivan, the family said “this tragedy was avoidable and should never have happened”.
“Laura should be here fulfilling her dream. As a mother to her beautiful son and wife to Fergal, she has missed and will miss all of her son’s milestones,” the statement said.
“The inquest highlights the urgent need to ensure basic clinical standards and protocols are followed in maternity care, which were unfortunately lacking in Laura’s case with fatal consequences.”
Earlier in the day, Fergal Mannion, Ms Liston’s husband, said he met his wife in Galway almost 20 years ago and it was “love at first sight”.
The couple had difficulty conceiving after they got married in 2019 and tried IVF and “everything was finally going to plan”.
During labour, Ms Liston got into a birthing pool to help with pain relief and delivered the baby in the pool at 10.58pm.
Mr Mannion said his wife held their son with “tears of joy in her eyes” after he was born.
She then tried to deliver the placenta but experienced difficulty and subsequently had episodes of fainting, blood loss, low blood pressure and vomiting.
In response to questions, Sandra Healy, the primary midwife, confirmed “in hindsight” she could have contacted the hospital at this stage due to Ms Liston’s clinical presentation.
Prof Amanda Cotter, consultant OBGYN, said that if this had happened in a hospital setting it would have been treated as an “emergency”.
Mr Mannion said she “did not look well” but the midwives reassured him his wife was ok.
“At one point Laura looked up at me and asked me to put her out of pain. She kept asking for help. She asked why nobody was coming for help.”
The midwives called for an ambulance and two arrived. Paramedics gave evidence that Ms Liston asked them to “help me” and the birthing pool contained a significant amount of blood.
Ms Liston went in one ambulance and was transferred to UHL, while Mr Mannion and their son went in another to the maternity hospital.
After their son was cared for, Mr Mannion was brought to UHL where he was told Ms Liston had died.
“I wish I could have been by her side. She was so excited to become a mother. It was all she ever wanted. I feel she was let down the one time she needed it,” he said.
Mr Mannion spoke about the impact the loss has had on him, saying his “life stopped” when she died.
“I am haunted by that night. I suffer from panic attacks. Every day is hard as I am constantly reminded of Laura. She isn’t there to share the important moments with our child. Our lives are shattered and will never be the same again.”
The inquest opened on Wednesday morning with an apology from the HSE for the “failings in care”.
Read out by Oonah McCrann SC on behalf of Ian Carter, chief executive of HSE’s Midwest acute and older people services, the HSE said the family trusted Laura would be safe and cared for “and that trust was broken”.
The HSE suspended home births in the midwest following her death and the service has not resumed since.
