Malak bled to death as vital treatment was delayed for 15 minutes
An emergency procedure, which may have saved the life of Malak Thawley during surgery at the National Maternity Hospital in Holles Street, was delayed for as long as 15 minutes after the alarm about her condition was first raised, the Irish Independent has learned.
Ms Thawley (34), who was undergoing a simple operation after she was diagnosed with an ectopic pregnancy, died three hours later.
One of her main blood vessels was accidentally injured by a sharp-pointed instrument used to create an opening early on in the surgery.
But it was not recognised for several minutes and, even when the accident was discovered, it was another 15 minutes before she received emergency treatment, according to an investigation report.
Her husband, Alan, who earlier was told the surgery on the Sunday afternoon would only take 45 minutes, never saw her alive again.
He has spoken of his heartbreak and how bereft he feels at the loss of his "beautiful wife, my best friend".
The couple were living in Ireland, where Mr Thawley, an American, was working. Mrs Thawley, a teacher, was a native of Syria.
The report of an internal hospital investigation into the case said the cut to a blood vessel was a rare event, which nobody on the surgical team had seen before. It led to Ms Thawley suffering a major loss of blood.
It pointed out that if a procedure, known as a laparotomy, to stop the bleeding was done earlier - along with a blood transfusion - the tragic outcome could have been altered.
Instead, time was spent doing various tasks such as making phone calls, preparing the surgical set and getting consultants who were at home to come to the theatre to try to save her.
By 5.04pm, at least 17 staff were directly involved in the patient's care.
Before the operation, Ms Thawley was described as anxious. She held one of the nurses hands tightly and asked two other nurses for prayers.
The report of the investigation team, led by obstetrician Dr Peter McParland, found other failures - including inadequate communication between members of the team about the critical nature of the patient.
A readily available supply of blood in the theatre should have been used immediately instead of waiting for other supplies to arrive.
Mr Thawley, who was on his own, became increasingly anxious about his wife.
He was told by staff at around 7pm that it was not progressing in a "straightforward manner". Within minutes he was informed the situation was "grave".
At 7.50pm he was given the heartbreaking news that she could die. Ms Thawley was certified dead at 7.57pm.
He was so distraught he could not bring himself to identify his wife's body on the night.
One of the doctors personally drove him home and gave him their mobile phone number.
Mr Thawley is receiving strong support from his solicitor, Caoimhe Haughey.
Holles Street has profoundly apologised to Ms Thawley's family and says it will implement the recommendations of the report.
A full hearing of an inquest into the circumstances of the tragedy is expected to be heard early next year.
Mr Thawley said he is an "emotional mess".
"I am trying to find a way to put one foot in front of the other," he said.