‘Missed opportunities’ to identify mother’s sepsis, inquest hears

Karen McEvoy (24) died on Christmas day, 2018, one week after giving birth

There were “so many missed opportunities” to identify that Karen McEvoy (24), who died on Christmas day 2018 a week after giving birth, was developing sepsis, an inquest into her death heard on Wednesday.

Tina Kelly, mother of Ms McEvoy's partner Barry Kelly, told Kildare coroner's court she had been concerned about the young mother's declining health in the days before her death.

She said Ms McEvoy had told a number of medics about worsening abdominal and lower back pain in the days after giving birth, but none suspected sepsis.

Ms McEvoy died at Naas General Hospital on December 25th, 2018, having given birth to her third child, Ruby, in the Coombe hospital on December 18th. She had had a "low risk" pregnancy and "straightforward" birth, and had been discharged home to Blessington, Co Kildare on December 19th.

Mr Kelly told coroner Dr Denis Cusack that Ms McEvoy had been "sore" with "pains in her stomach, her lower back and upper right and left legs" from the following day, December 20th.

She visited public health nurse Doreen O’Sullivan in the Vista primary care clinic in Naas on December 21st. He said Ms McEvoy told him afterwards that Ms O’Sullivan had advised it was “normal” to have abdominal pain after giving birth.

Ms O’Sullivan, however, said Ms McEvoy had not indicated she had any pain, though agreed she left a table in Ms McEvoy’s chart, in which pain would be recorded, blank.

Blood pressure

She told the inquest she had not recorded Ms McEvoy’s blood pressure or temperature as at the time her clinic did not have a thermometer or a sphygmomanometer (used to measure blood pressure).

Dr Cusack said it was a “strange omission” that she left blank the table in which to indicate whether Ms McEvoy had any abdominal, head or other pain.

Ms O’Sullivan said it was “an omission”. She said she would have initiated a care plan if Ms McEvoy had indicated she had pain.

Asked if she would have filled in the form at the same time as talking to a mother she said: “More or less.”

Esther Earley, BL, for Mr Kelly said the omission "gives great concern to the family that this missed opportunity where there was a complaint about tummy or abdominal pain, that this wasn't documented".

The inquest heard at an outpatient appointment at the Coombe hospital on December 23rd, 2018, Ms McEvoy was in such pain she was using crutches to walk, Mr Kelly said. "She was told by the doctor it was bad sciatica but if the pain got worse to go to Tallaght for an X-ray. No bloods were taken and we were sent on our merry way."

Speech slurred

On Christmas Eve she was still very sore, he continued, swollen and needed help getting into bed. On Christmas Day “her whole body was swollen, her colour was pale, her speech was slurred” and she was too sore to be touched.

Ms Kelly said she called an ambulance when she saw Ms McEvoy that morning. “Her speech was slurred. I thought she had actually had a stroke, I knew she was in trouble.”

Advanced paramedic with the HSE Liam O’Neill believed Ms McEvoy had progressed from sepsis to septic shock when he attended to her on Christmas morning. He said she had a pulse of 160 beats per minute, a breathing rate of 30 per minute and her blood pressure was “very low”. He agreed she had “very deranged vital signs”.

The inquest heard from Dr Thivnashi Naidoo and Dr Rita Chaudry of the sustained and exhaustive efforts to resuscitate Ms McEvoy following her arrival Naas General Hospital shortly before noon. She was pronounced dead shortly before 4pm.

Pathologist Dr Michael Jeffers gave the cause of her death as "multi-organ failure secondary to puerperal sepsis, due to group A streptococcal infection".

The inquest continues before a jury of two women and five men at Athy Courthouse on Friday.