A jury has returned a verdict of death by medical misadventure in the case of Sally Rowlette who died in Sligo Regional Hospital on February 5th last year the day after she gave birth to her fourth child.
After the verdict, her husband Seán said he hoped lessons had been learned “and I hope it starts tomorrow”.
He had got answers “and I hope it will save the lives of other women”.
He said his family had been turned upside down and he was now facing Christmas once more without his wife. “Christmas will be hard. I don’t look forward to these things now”, said the 39-year-old who held a photograph of his wife as he spoke to reporters.
Mr Rowlette said it had been hard for his four children and for himself.
He had struggled since he lost his wife to be mother and father to his kids, and it was hard to answer their questions. “The kids go to bed at night and you turn the key in the door and you are on your own. It is hard,” he said.
The verdict comes two months after a jury recorded the same finding in respect of Dhara Kivlehan from Dromahair, Co Leitrim who died at the Royal Victoria Hospital in Belfast eight days after her baby was born in Sligo hospital in September, 2010. Like Sally Rowlette, she suffered from HELLP syndrome (a severe form of pre-eclampsia).
Michael Kivlehan, Dhara’s husband, attended the three-day inquest this week in solidarity with the Rowlette family.
After the verdict. Damien Tansey, solicitor for the Rowlette family, said they were now considering all their options, but it was likely that they will initiate civil proceedings against the HSE. His colleague Roger Murray said they would be trying to track down Ms Rowlette's obstetrician Dr Murshid Ismail who left Sligo months after Ms Rowlette's death. They would also try to trace the ICU consultant who left the hospital that night as frantic efforts to save the young mother continued.
The jury, who over three days listened to harrowing evidence of Ms Rowlette’s dramatic deterioration after she arrived in the hospital on February 4th last year, made a number of recommendations.
They urged that a senior consultant be contacted immediately in the event of a medical emergency, to “advise, direct and monitor” until the incident is resolved. They also called for an indepth comprehensive review following similar tragedies and they called for a communications strategy to ensure proper liaison with families.
The jury recommended counselling for mothers who experience conditions such as HELLP syndrome to advise them on any risks for future pregnancies and they called for careful monitoring in the event of high-blood pressure or the risk of HELLP in pregnancy.
Among the issues highlighted by Mr Rowlette’s legal team was the delay in administering therapy to control Ms Rowlette’s “off the wall” blood pressure and the fact that when she was transferred to intensive care after delivery there was no consultant there to monitor her condition. The jury heard that there had been an ICU consultant on call had gone home .
It also emerged that Ms Rowlette’s obstetrician Dr Murshid Ismail, “abruptly” resigned his post some months after her death and couldn’t be contacted to appear at the inquest.
Poignantly, one nurse who cared for Ms Rowlette in her final hours , recalled giving a lock of her hair to her husband shortly before he said goodbye to her.
In one of the uncontested statements to the inquest which was not read to the jury, staff nurse Elaine Duignan recalled that a transplant coordinator was speaking to the family when she arrived for night duty. She recalled giving Mr Rowlette a lock of his wife’s hair before he got time alone with her to say goodbye.
Mr Rowlette told the jury that as he sat by his wife’s bed he decided that if she did not make it he would donate her organs, as she was a generous person and would have wanted that. Three people received transplants as a result.
Conor Halpin SC for the hospital extended sympathy to Mr Rowlette and his family. He said the doctors and nurses who cared for Ms Rowlette were decent hard working people who were terribly upset by what happened.
Ms Rowlette had “extremely high blood pressure” when she arrived in labour at Sligo Regional Hospital, but there was a delay in administering the appropriate medication, an expert witness told the inquest earlier today.
Dr Peter Boylan also said there had been an "error in clinical judgement" in having two-week gaps between hospital visits when Ms Rowlette's blood pressure increased towards the end of her pregnancy, given her history of HELLP syndrome.
Ms Rowlette presented at the hospital with a medical emergency “requiring urgent intervention” to control blood pressure, Dr Boylan told the jury.
It “would have been better” if there had not been a 40-minute wait before treatment began, the consultant obstetrician gynaecologist said.
The former master of Holles Street said it was “disappointing” there was no consultant in the ICU for several hours after Ms Rowlette was transferred there.
Mr Tansey told him there had been a consultant on duty who had gone home. “There was a dangerously ill woman dying before their eyes,” said Mr Tansey.
Mr Boylan said that the blood pressure problem had settled a bit initially, but he agreed it was disappointing there was no one of consultant rank there.
He agreed with Mr Tansey that in his hospital, he would expect a consultant to sit at the bedside of a woman in that condition and administer bolus after bolus of medication , changing it if necessary to get blood pressure down.
It was “most unfortunate” this did not happen, he agreed.
He told coroner Eamon MacGowan that Ms Rowlette arrived at the hospital at 1.20am on February 4th, but hypertension medication was not administered until 2.05am “and it appeared that medical assistance was not sought until 1.40am”.
“There was a delay in initiating aggressive anti-hypertensive therapy and when anti-hypertensive therapy was initiated there was a slow response,” the consultant added.
He was speaking on the third day of the inquest into the death of the 36-year-old who died on February 5th, 2013, the day after the birth of her fourth child at the hospital.
Ms Rowlette was the victim of a broad systems failure, Mr Boylan told the inquest. He said there was a problem with part-time staff who might not understand the way things were done in individual hospitals.
This was a difficulty in the Irish health system, not just in Sligo. The consultant agreed that Ms Rowlette was the victim of a broad systems failure, as was her husband and four children.
Ms Rowlette, from Dromore West, Co Sligo, suffered a massive brain haemhorrhage and swelling of the brain associated with HELLP syndrome. .
Commenting on the records showing the dates of Ms Rowlette’s hospital appointments in the final stages of her pregnancy, Dr Boylan also said that it was “not wise” for a woman with a history of HELLP Syndrome, who is showing signs of hypertension, to have two-week intervals between hospital visits.
Mr Tansey put it to him that there was nothing untoward until the ante natal visit on January 14th, when Sally’s blood pressure was up which was “the first sign of trouble”.
Asked what he would have done, he said she should have visited her GP after a few days or come to the hospital to have her blood pressure monitored for a few hours.
If it remained elevated it would have been important to do blood tests to detect signs of pre-eclampsia or HELLP. Adverse liver results might have been detected if blood tests were done at 36 and 38 weeks, he agreed.
Mr Boylan said if he had detected HELLP at 37 weeks, he would have induced her at that stage.
He pointed out that 20 per cent of women who have had HELLP will develop pre-eclampsia in subsequent pregnancies. The recurrence rate of the syndrome is 5 per cent.
The jury has heard that Ms Rowlette did suffer from HELLP syndrome during her second pregnancy, but there is a dispute as to whether she was aware of that.
Sally’s history of HELLP syndrome put her at increased risk of developing pre-eclampsia “and a smaller increased risk of developing HELLP syndrome again”, Dr Boylan said.
The consultant noted that when Sally gave birth to her third child the past history of HELLP was “noted prominently on the hospital chart ante natal page”.
He pointed out that there were signs of increasing blood pressure at her last two ante-natal visits when she was at 35 and 37 weeks, “but more intensive monitoring does not appear to have been initiated”.
Medical records showed the Co Sligo woman was “very distressed and vomiting” and was also complaining of a headache when she arrived at the hospital.
When the registrar Dr Ahmed Koura arrived at 1.48am she was vomiting, distressed and complaining of severe headache and epigastric pain, but with no visual disturbances. A urine sample contained protein. At 2am a decision was made to administer intravenous Labetalol to lower blood pressure.
He said Mrs Rowlette had clearly developed very acute onset hypertension. The slow maternal heart-rate, in addition to the vomiting, indicated intra-cranial pressure and “required an urgent response”.
The consultant pointed out that Sally Rowlette’s fourth pregnancy had been uncomplicated until she showed signs of developing hypertension at just less than 36 weeks. She was not admitted to the hospital for further monitoring .
When she presented at the hospital at 39 weeks she had fulminating pre-eclampsia with severe hypertension, protein in her urine, headache, vomiting and epigastric pain. Initial blood tests showed a normal platelet count of 146 (normal being 140 to 450).
He said the next platelet count he could find was at 6.13am when it had fallen to 31. Soon after this, she developed intra cranial haemhorrhage.
He said “undoubtedly” the low platelet count predisposed her to the development of the intracranial bleed. The severe headache with vomiting, and the low pulse rate before delivery suggested a significant rise in intracranial pressure.
Dr Boylan said consultant obstetrician Dr Heather Langan had done the correct thing when she delivered the baby on confirmation that the cervix was fully dilated.