Safety flaws highlighted in maternal death probe

  • Niall Hunter, Editor

An investigation into the death of a Nigerian woman in the care of Dublin's Rotunda Hospital in March of last year has indicated major flaws in the woman's treatment and hospital policy and has issued recommendations on how care can be improved 'to prevent future harm'.

Health Minister James Reilly, in a Dail reply this week, revealed 10 of the 11 recommendations made on foot of the probe into the death of 32-year-old Bimbo Onanuga 14 months ago. However, the full findings of the investigation by the HSE into factors contributing to her death have yet to be released.

A further investigation is being carried out into the maternal death of an eastern European woman at the Rotunda in March of this year.

The recommendations published indicate that there were major deficiencies identified in the care of the Nigerian woman.

The HSE, in a statement, extended its deepest sympathy to the family and friends of the deceased. However, the family has as yet not received the report of the review as the hospital has had difficulty contacting them, the health executive said.

A HSE spokesperson added that the coroner's office had been advised of the case but the coroner subsequently closed the case without holding an inquest. It said the case had also been reported to CMACE, the confidential maternal and child enquiry system.

Ms Onanuga attended the Rotunda on March 1, 2010 when seven months pregnant and it is understood that she was told her child had died in utero.

She was treated and advised to return for further treatment the following Thursday, but is understood to have been admitted to the Rotunda in severe pain on the Wednesday. Ms Onanuga's condition deteriorated, she was transferred to the Mater Hospital and was subsequently pronounced dead later that day.

The recommendations of the report into the death were revealed by Dr Reilly in a reply to Socialist Party TD Clare Daly. They include:

* A demand that the hospital update its training needs analysis of all midwifery and nursing staff on its gynaecology ward.

* There is a need to identify clinical pathways on management of women with an intrauterine death in the third trimester to complement existing medical management policy.

* Guidelines for medical management of intrauterine death should be revised in line with a review of medical literature.

* A brief operational outline of the hospital's gynaecology department should be developed to assist staff sent there 'on an occasional/intermittent basis'.

* There should be a designated individual with responsibility for coordinating, monitoring and auditing basic life support attendance and advanced life support skills attendance, ideally a designated resuscitation training officer.

* An obstetric early warning system should be introduced.

* Details of all patients for induction of labour, regardless of place of induction, should be centrally documented.

Other recommendations include the need for an analysis of hospital doorways to establish the feasibility of moving a bed in a critical event, the need to set up additional phone lines in the relevant ward, and that a review be carried out of the possibility of emergency call bells or designated phones for emergencies in each room.

The Minister said he had been informed by the HSE that all but one recommendation - on the need for a resuscitation training officer, had been implemented.

Discussions were underway in the HSE to bring the implementation of this recommendation to conclusion, he said.

One of the 11 recommendations could not be revealed as it was confidential to the individual patient, the Minister said.

While full details of the review into Ms Onanuga's death have not been published, the recommendations indicate that serious safety flaws were identified in the woman's care and in the hospital's systems to deal with emergency cases such as hers.

The Minister told Deputy Daly that the case was investigated under the HSE's National Incident Protocol, and the probe identified factors that contributed to the maternal death.

The recommendations were drawn up to address the contributory factors in Ms Onanuga's death 'and to prevent future harm' arising from these factors.

Asked to comment on the case, the HSE told the death had been the subject of an internal and independent external investigation, instigated by the Rotunda in line with the HSE's Incident and Accident Reporting and Management Policy

It said the Master of the Rotunda Hospital met with family members in the days following the death and the family were advised by letter of the reviews taking place. Staff from the hospital had attended the funeral.

The HSE said the recommendation on resuscitation practice was in the final stage of implementation.

It added that the learning from the Rotunda review has been sharted with other obstetric units in the HSE Dublin North-East region and with the HSE nationally via the National Incident Management Team.

The HSE said the internal final report of the incident made the 11 recommendations, but "the external reviewers' report did not recommend any changes in the management of this or other cases on foot of that review."

Ms Onanuga is understood to have a daughter with cerebral palsy and she was her primary carer.

The HSE is also investigating the death of another patient at the Rotunda, believed to be from Poland, in March of this year. The woman is believed to have collapsed in the Rotunda and transferred to the Mater, where she died.

Maternal deaths are rare in Ireland, the HSE said. According to the Central Statistics Office, the rate was three per 100,000 live and stillbirths in 2007 and four per 100,000 in 2008.

However, some experts believe the true maternal death rate is under-reported due to the criteria currently used, and the real rate could be around 10 per 100,000 if the criteria were changed.

A maternal death is currently defined as one occurring during or shortly after a pregnancy.

There have been a number of other high-profile maternal death cases recently in Irish hospitals.

The HSE recently apologised and admitted negligence in settling a legal case with the family of Tanya McCabe, who died at Our Lady of Lourdes Hospital in Drogheda in 2007 along with one of her twin sons. The other twin survived.

In April of this year, a woman from Monaghan died at the same hospital after giving birth. Her baby was delivered safely.


Discussions on this topic are now closed.