Malak case report calls for external review into all maternal deaths
A review of the investigation into the death of Malak Thawley, who died in the National Maternity Hospital, has called for all maternal deaths to be subject to external, independent examination.
The review looked at the internal report carried out by the National Maternity Hospital, Holles Street, into the death of Mrs Thawley (34) in May last year after a blood vessel was punctured during surgery for an ectopic pregnancy.
Her husband Alan Thawley wants an independent inquiry into his wife's death, the cause of which was deemed medical misadventure at a recent inquest.
Following pressure from Mr Thawley and the family's solicitor Caoimhe Haughey, Health Minister Simon Harris agreed to a review of the internal investigation by an expert panel, led by Rotunda Hospital obstetrician Dr Peter McKenna.
Dr McKenna's report said all direct maternal deaths - which account for two to three tragedies a year - should be reviewed externally to the hospital or hospital group where it happened.
It said: "Such an approach is justified on the basis of the rarity of the event and the opportunity that they present for learning."
It also called for all these reports to be submitted to the National Women and Infants' Health Programme for their information and analysis. The death should be notified within 48 hours.
The review said the Holles Street report into Mrs Thawley's death should have included a vascular surgeon. This is in light of the injury which led to her death.
If there is a further external examination of her death, it should look at a range of areas, including training of staff in the event of blood loss and a loss of blood pressure during a keyhole operation.
It also wants to look at the practice of carrying out non-urgent surgery out of hours.
There should also be a probe of the resources needed if non-urgent surgery is done at the weekend or out of hours and whether normal weekday staffing is required, such as a senior consultant being in attendance.
Mrs Thawley had the surgery on a Sunday. The inquest highlighted a number of failings in her care.
Mr Thawley has spoken of his anguish at his wife's death and said he has not lived a single minute of his life since she died.
"It is utterly devastating how much a single event can destroy a person... there is no present moment," he added.
The couple were living in Blackrock in Dublin where Mr Thawley, an American, works. Mrs Thawley was seven-weeks pregnant at the time of her death.
The hospital has changed several procedures since the tragedy.