The National Maternity Hospital (NMH) in Holles Street should have had a plan in place to treat a pregnant diabetic who had a rare resistance to insulin, the Dublin Coroner said yesterday.
As he returned a verdict of medical misadventure at the inquest into the death of 35-year-old mother-of-two Jennifer Crean, Dr Brian Farrell said that she was a high-risk patient and the absence of a specific plan had a significant impact on her care.
Mrs Crean, from Ashford in Co Wicklow, had a heart attack as doctors carried out an emergency C-section after she went into septic shock at the NMH on July 2, 2008.
She suffered severe brain damage as a result of a lack of oxygen following the heart attack and remained in a coma until her death at St Vincent's Hospital on February 10, 2009.
During the eight-day inquest, Dublin Coroner's Court heard Mrs Crean had a rare resistance to insulin injections and, as a result, the drug was delivered into her system using a central intravenous line, which became infected, and on July 2, she went into septic shock.
Dr Farrell said that despite the involvement of a number of consultants in her treatment, no specific care plan had been put in place for Mrs Crean.
He will write to the NMH recommending that specific care plans should be available in the case of high risk patients.
After the verdict, Jennifer's husband Francis Crean said: "I hope that Holles Street will learn some lessons from this."
Late last year, the High Court approved a settlement of €690,000 against the NMH for Mr Crean and the couple's two sons Adam (11) and Daniel (4). In addition, Adam settled his action for damages for nervous shock for €40,000.