Doctors ruled out the possibility that a woman who died after childbirth in UHK was bleeding, despite concerns being raised multiple times by nurses on duty.
The inquest of 34-year-old Tatenda Mukwata, who died at University Hospital Kerry on April 21st 2022, continued yesterday afternoon at Tralee Courthouse.
Ms Mukwata had lived in a direct provision centre in Kenmare with her three daughters, and had given birth to her fourth daughter before 8pm, before she died just over six hours later.
Anaesthetic registrar on the night, Dr Sumanth Samson, said Ms Mukwata was stable throughout her C-section surgery, which he described as uneventful.
Ms Mukwata’s blood pressure decreased and her pulse increased on consecutive readings between 9:15 and 9:30pm.
Senior counsel Dr John O’Mahony put it to Dr Samson during cross examination that these were very significant issues, and strikingly worrying readings.
Dr Samson told the inquest he first thought these issues were related to spinal block, the anaesthesia Ms Mukwata had been given for the C-section.
Dr O’Mahony put it to Dr Samson multiple times that these particular readings pointed to an overwhelming probability that Ms Mukwata was bleeding internally, to which Dr Samson repeatedly replied it could have been caused by other things.
Dr Samson said when he became concerned, he contacted the surgical team who told him there was no indication of bleeding, and he accepted a diagnosis of sepsis.
Dr Samson agreed with Dr O’Mahony that had this colossal dramatic drop in her levels had been identified and steps taken to address it, Ms Mukwata’s life would have been saved.
Dr Samson said it was correct that there was no checking of whether there may be internal bleeding.
Dr Samson also told the inquest that the Anaesthetic Consultant on the night reviewed Ms Mukwata at 9:40 that night, determined her stable, and left the hospital.
Ms Mukwata was reviewed by gynaecologist Dr Fahad Hendricks at 11:15pm that night, and general nurse Andrea Horan told the inquest she remembers asking if Ms Mukwata could be bleeding, to be told that this was not a surgical issue.
ICU nurse Siobhán Ó Nualláin gave evidence that she and nurse Pauline Sheehan attended Ms Mukwata’s bedside shortly after 11:30pm, and upon being told her vital signs were not stable, both nurses queried if there was a possibility the patient was bleeding.
Ms Ó Nualláin said that the doctors had concluded there was no active bleeding, and the patient was treated for sepsis and septic shock.
Ms Mukwata was declared dead just three hours later, after 90 minutes of attempted resuscitation from cardiac arrest.
Ms Ó Nualláin also stated staff were already redeployed around the hospital, and staff were unable to back fill all staffing deficits with amount of staffing available on duty across hospital.
