A coroner has returned a verdict of medical misadventure at an inquest into the death of a biopharmacist at Mayo University Hospital (MUH) last year just hours after she gave birth to a healthy baby girl.
Mayo Coroner Pat O’Connor said a number of factors led to Nayyab Tariq’s death on March 22nd, 2020. The most significant, he said, appeared to have been a concealed haemorrhage which did not become obvious despite monitoring of the 28-year-old’s vital signs.
Mr O’Connor said that despite having a post-partum measured blood loss of some 500ml, Ms Tariq did not seem to have had any significant difficulties while in the labour ward. However, he said her blood pressure remained low while her heart rate was high, and she experienced nausea.
He noted that clinical medical findings from the labour ward were not fully communicated to the operating theatre staff. Mr O’Connor said that on transfer to the operating theatre there were clinical signs of tachycardia, hypotension and an increased respiratory rate.
The coroner added that Ms Tariq had a general anaesthetic in the theatre, which made physical observations of her condition more difficult. She had the placenta removed manually and and suffered a cardiac arrest, and despite efforts to resuscitate, she died.
The coroner made a recommendation to MUH and the Saolta Group, which runs it, that all the findings and recommendations made by Prof John Morrison and a review group earlier this year be actively followed and implemented.
Mr O’Connor expressed sympathy with Ms Tariq’s family and the MUH staff, particularly those who cared for the deceased and suffered a great deal from her death.
Ms Tariq and her husband, Ayaz Ul Hassan, were living in Ballyhaunis at the time and her daughter, the couple’s first child, was named after her. She and Mr Ul Hassan are originally from Lahore in Pakistan.
Conor Halpin SC read a statement on behalf of Catherine Donohoe, the manager of MUH, in which she expressed sympathy with the bereaved family, stated she was “truly sorry” for what happened to Ms Tariq and that she hoped lessons would be learned from the incident.
Speaking outside Swinford Courthouse after the verdict, Mr Ul Hassan’s solicitor Johan Verbruggen, of Callan Tansey Solicitors, said it was clear from the evidence heard that protocols for managing postpartum haemorrhage, in place at MUH since 2012, were not properly followed.
He said there was a delay in recognising Ms Tariq’s deterioration from massive blood loss which “naturally led to a delay” in her receiving life-saving intervention.
“What should have been the happiest day of their lives became the ultimate tragedy for Ayaz,” he said. “He lost his wife, his soulmate. Their daughter will never get to meet her mother and each birthday will carry a note of sadness marking the anniversary of her death”.
Earlier, consultant pathologist Dr Fadel Bennani gave evidence that Ms Tariq died in rare and unexpected circumstances a few hours after an uncomplicated vaginal delivery of a healthy baby.
Dr Bennani said the cause of death, in his opinion, was multifactorial and was due to spontaneous intra-peritoneal haemorrhage due to extensive extra-uterine decidualisation in the pelvis and pulmonary thromboembolism due to thrombosed para-uterine veins.