A woman who had just given birth in UHK died by medical misadventure and her death was probably preventable, an inquest has found.
34-year-old Tatenda Faith Mukwata died in the early hours of the 21st April 2022, just over six hours after giving birth to a healthy daughter, Eva by Caesarean section.
The jury of five women and two men deliberated for around one hour and 15 minutes yesterday evening, before reaching their unanimous verdict.
The jury also made seven recommendations arising from the death of Ms Mukwata, for which the HSE had earlier this week apologised.
Consultant obstetrician Dr Mary McCaffrey told the inquest if protocols had been followed, Ms Mukwata could have been correctly diagnosed as early as 9pm on April 20th.
The inquest previously heard the anaesthetic consultant, Dr Iftakir Ali, deemed Ms Mukwata stable at 9:40pm, and left the hospital.
Under cross examination, Dr Ali said he checked on Ms Mukwata before he left the hospital, and the nurse present said she was okay, and he was told nothing extraordinary about her condition.
This is despite readings from the previous half hour which showed her condition was deteriorating, and Dr Ali said she was not critical when he was there but may have got worse after he left.
Dr Mary McCaffrey, consultant obstetrician, said the possible sepsis diagnosis was given by gynaecologist Dr Fahad Hendricks, because of a spike in Ms Mukwata’s temperature post-birth.
Dr McCaffrey said she expected that the sepsis protocols were immediately being followed, which would have meant bloods were taken straight away.
She said if this was followed, doctors would have known Ms Mukwata wasn’t suffering sepsis once blood results were back, and eventually told the inquest this could have been identified as early as 9pm.
Dr McCaffrey said she cannot guarantee this early identification would have saved Ms Mukwata’s life, as it would have been a complex procedure to address the bleeding.
The jury asked Dr McCaffrey why she did not remain at the hospital after requesting bloods be done to get the results, and Dr McCaffrey replied she was contactable by phone the entire night, after she left the hospital at 9:50pm.
Dr McCaffrey told the family she was so sorry that this happened on her watch.
The jury eventually reached a verdict of death by medical misadventure, and a cause of death of catastrophic bleed, haemorrhage and shock, due to arteriovenous malformations, which are irregular connections between veins and arteries, following Caesarean section.
The jury also found that the death was probably preventable, and there was a misdiagnosis followed by a failure to investigate other possible differential diagnoses, and made seven recommendations to improve practices in hospitals.
