The inquest into the death of a woman (34) following the birth of twins at Our Lady of Lourdes Hospital in Drogheda in March 2007 has returned a verdict of medical misadventure.
Tania McCabe presented at the hospital on March 6th, 2007, believing her waters were breaking. However, her consultant believed she had "an episode of urinary incontinence rather than a rupture of membranes", a HSE report found.
She was kept in overnight and the following morning, a midwife noted she believed the woman's waters had broken. Ms McCabe was discharged and when she returned to the hospital more than 30 hours later to give birth, sepsis had set in, which was the main cause of her death.
One of her twins also died.
The coroner, Mr Ronan Maguire, said the HSE accepted there had been a "catastrophic systems failure" in her case and the only verdict he could give was one of medical misadventure.
He said this had been one of the most appalling tragedies he had ever come across as a coroner.
He said maternal death was now "very rare" but a systems failure at the Lourdes hospital led to the death of Ms McCabe.
He said that fact had been recognised in a review carried out by the HSE and in a rider to his verdict he wanted to state he believed it was "extremely important that the 27 recommendations in that review be implemented urgently".
The coroner returned an open verdict about her son's death.
Aidan McCabe, the husband of the dead woman, told the inquest his late wife was at work at Santry Garda Station on March 6th when she felt her waters breaking. But at the hospital an ultrasound indicated there was still fluid around the twins in her womb. A separate test also indicated her water's hadn't broken. She was kept in overnight, and a bad urine infection was detected and she was put on antibiotics.
He said the next morning, March 7th, he got a text message from Tania, who was just six months pregnant, saying a midwife who looked at her during the night was sure her waters had broken. Following further tests, she was discharged.
The following day March 8th she had pains in her lower abdomen, he said, and remained in bed most of the day. They decided to return to the hospital that evening and when she was examined by obstetrician Dr Shane Higgins, she was 5cm dilated and underwent an emergency caesarean section. Shortly after 9pm she gave birth to twins Adam and Zach, and they were immediately told Zach wouldn't make it.
Afterwards Mr McCabe said he noticed a lot of blood in the bed under Tania. In the hours that followed she seemed agitated and restless and seemed just about able to recognise him. She was taken to intensive care in the early hours of March 9th and when Dr Higgins was called he said he would take her back to theatre and might have to do a hysterectomy. Dr Higgins returned around 6am and said he was sorry, that she had died in theatre. Mr McCabe said he was totally shocked.
He agreed with his counsel Bruce Antoniotti that a review of her case by the HSE found a working diagnosis of ruptured membranes was not made when his wife was first admitted to the hospital and that if it had been it was unlikely she would have been discharged home. The review also found septic shock was not recognised and diagnosed quickly when she was admitted the second time.
Mr McCabe said his foremost concern was that what happened in his wife's case did not happen anyone else and that the recommendations of the review group were put in place.
Barbara Corcoran, the mother of the deceased, told the inquest that only days earlier she had been shopping with her daughter in Dublin, looking at prams and baby clothes. But when she rushed to the hospital after her daughter had the twins and saw the theatre in which she died it was like "an abbatoir", she said, adding she would never forget the appalling sight of seeing her daughter in this way.
She broke down as she told the coroner she hoped this never happened anyone else again. She also said it was sad it had taken the hospital so long to put the recommendations of the review group in place.
The deputy state pathologist Dr Michael Curtis said he concluded cause of death was as a result of multi organ failure and post partum haemorrhage due to sepsis as a result of an ascending E Coli infection.
Adrienne Egan, counsel for the hospital and the HSE, said the hospital wanted to express its deepest sympathy to the dead woman's family. "We accept that this is a tragic event and one that is deeply regretted by all," she said.
She added that staff who cared for Ms McCabe were devastated at the outcome.
Furthermore she said the hospital accepted in full the recommendations of an inquiry into Tania McCabe's death and most of them had already been implemented or were in the process of being implemented.