Coroner records verdict of medical misadventure in case involving National Maternity Hospital

Plan should have been in place to treat medical condition which led to pregnant woman’s death

The National Maternity Hospital in Holles Street should have had a plan in place to treat a pregnant diabetic who had a rare resistance to insulin, the Dublin city coroner said yesterday.

As he returned a verdict of medical misadventure at the inquest into the death of 35-year-old mother of two Jennifer Crean, Dr Brian Farrell said that she was a high-risk patient and the absence of a specific plan had a significant impact on her care.

Mrs Crean, from Ashford in Co Wicklow, had a heart attack as doctors carried out an emergency Caesarean section after she went into septic shock at the hospital on July 2nd, 2008. She suffered severe brain damage as a result of a lack of oxygen following the heart attack and remained in a coma until her death at St Vincent’s hospital on February 10th, 2009.

Over the course of the eight-day inquest, Dublin Coroner’s Court heard that Mrs Crean had a rare resistance to insulin injections and, as a result, the drug was delivered into her system using a central intravenous line. This was prone to infection and had to be replaced regularly.


She presented at the hospital on June 29th, 2008, complaining of abdominal pain and sweating profusely. Her husband, Francis Crean, said the couple had a heated argument with staff that the line should be changed but were told there was no one available. Mrs Crean was so concerned she insisted on naming the couple's unborn child.

Staff at the hospital were advised to remove and replace the line, which was confirmed to be infected, by her consultant anaesthetist. However, following several failed attempts to find another access point to intravenously administer Mrs Crean’s insulin, the infected line was left in place.

On the afternoon of July 2nd, she went into septic shock, forcing doctors to carry out a Caesarean section. However, she had a coughing fit while being intubated, which closed off her airway, and she went into cardiac arrest depriving her brain of oxygen for at least two minutes.

In summing up, Dr Farrell said despite the involvement of a number of consultants in her treatment, no specific care plan had been put in place for Mrs Crean. Time was of the essence in this case, he said, and a plan would have helped the clinicians on duty.

He will write to the hospital recommending that specific care plans should be available to on-duty staff in the case of high-risk patients.

Speaking after the verdict, Mr Crean said that he hoped the hospital would learn from his wife’s death. “This has been a long and harrowing four years for our family. I hope that Jennifer’s death was not in vain. I really mean this. I hope that Holles Street will learn some lessons from this and that new protocols are put in place to make sure that this never, ever, happens again to anybody else,” he said.

Late last year, the High Court approved a settlement of €690,000 against the hospital for Mr Crean and the couple’s children, Adam (11) and Daniel (4), who was successfully delivered by Caesarean section. In addition, Adam settled his action for damages for nervous shock for €40,000.