A JURY has returned a verdict of medical misadventure in the death of Sally Rowlette, the 36-year-old woman who died at Sligo Regional hospital last year a day after giving birth to her fourth child.
The jury of five men and four women at Sligo court house took two hours and 15 minutes to reach the verdict.
Sligo Coroner Eamon MacGowan had recommended the verdict to the jury, telling them: “Medical misadventure was an intentional act or omission that features misfortune, causing death. It didn’t apportion blame.”
Sally died from a brain haemorrhage on February 5 last year, a day after arriving at the hospital complaining of illness including a severe headache.
Her death was caused by HELLP syndrome, a severe form of pre-eclampsia which leads to very high blood pressure.
The inquest heard that Sally had suffered from the same illness when she gave birth to her second daughter Abbie in 2007 but neither she nor her husband had been told.
Mr MacGowan said there had been opportunities before Sally’s death to have her assessed for high blood pressure and this hadn't happened.
The jury added ‘riders’ or recommendations to their verdict.
• that post-natal care of women who suffer from HELLP syndrome continue
• in the vent of a pregnant woman presenting in similar circumstances that a senior consultant be immediately available to advise and direct all procedures and remain available until the incident is resolved
• An in-depth review of similar incidents involving all personnel and shared within the hospital for future.
• A liaison system should be put in place to deal with relatives at the time of a medical emergency
• Careful monitoring of patients who have suffered from HELLP syndrome in the past should take place after a pregnancy.
Speaking after the case widower Sean Rowlette, (39), said he had finally received answers on his wife had died.
“I found out a lot of things that I never knew about,” said Sean, from Dromore West.
“I want to thank my solicitors Damian Tansey and Roger Murray for the huge amount of work they have put into this case.
“Sally’s birthday is next week and it is a difficult time for me and the children. But at least now we know what happened in the weeks, days and hours leading up to her death when so many opportunities were missed.
“My aim in all of this has been to make sure no other family has to go through what we are going through; that lessons are learned so that women going into hospital to have children don’t end up like Sally.”
The court heard the HSE has already implemented a new system where mothers who suffer from HELLP syndrome meet a consultant after recovery and before they consider another pregnancy.
The inquest at Sligo court house had heard three days of evidence in the case in which experts said a consultant should have induced birth weeks before.
In his summing up to the jury, solicitor Damian Tansey representing widower Sean Rowlette (39), from Dromore West, Co Sligo, said his client had spent every day since his wife’s death trying to find out what happened to her.
Mr Tansey said the case was about the death of a young woman with dreams of a future ahead of her “who died before her time in one of the cruellest events imaginable”.
He recalled how Sally Rowlette had kissed her three eldest children before going to hospital and promised she’d see them the next day. They would never see their mother again, he said.
HSE barrister Conor Halpin said new guidelines were in place as a result of Sally’s death including counselling for mother’s who have suffered from the illness.
The jury also heard that the ICU consultant on duty on the night of Sally’s admission - a Dr Tariq - went home at 3am. Sally didn’t see an ICU consultant again until just before 8am with a different consultant came on duty.
Dr Tariq and Dr Ismail have since left Sligo hospital.
Expert witness Dr Peter Boylan, a consultant obstetrician at the National Maternity Hospital, said in his evidence earlier today that Sally’s obstetrician Dr Murshid Ismail should have referred Mrs Rowlette for further analysis when she was checked at the hospital for her blood pressure on January 14.
An initial reading that day had recorded a blood pressure of 140/92 which was high.
Dr Boylan said Mrs Rowlette should have been referred to her GP for another reading within a few days or should have been brought in to hospital for further monitoring.
Instead he said, Dr Ismail - who is in Saudi Arabia and could not be called to the inquest - delayed the review for two weeks.
He repeated a two-week referral a fortnight later despite Mrs Rowlette's previous history of HELLP syndrome.
“It was an error of clinical judgement to refer her for another two weeks on both occasions,” Dr Boylan said.
Mr Rowlette, who now looks after his four children aged between 21 months and nine, sat with his head bowed in the court as Dr Boylan gave his evidence.
His wife had suffered from HELLP syndrome on the birth of her daughter Abbie in 2007.
The inquest has already heard that she and her husband were not told of the illness.
Dr Boylan criticised the lack of urgency in Sally’s care when she was admitted to Sligo Regional Hospital at 1.20am on February 4.
“At her presentation she had extremely high blood pressure and was commencing labour at the same time,” said Dr Boylan.
“There was a delay in initiating aggressive anti-hypertensive therapy and when anti-hypertensive therapy was initiated there was a slow response.
“Ms Rowlette had clearly developed very aggressive acute onset hypertension (blood pressure). The presence of a slow maternal heart-rate in addition to the vomiting indicated raise intra-cranial (brain) pressure and required an urgent response.
“Ms Rowlette presented to the hospital at 1.20am but hypertensive medication was not administered until 2.05am and it would appear that medical assistance was not sought until 1.40am.”
Dr Boylan said Sally Rowlette should have been treated on her arrival in hospital in the same way as a someone arriving at the hospital who had suffered a heart attack.
“It was a medical emergency,” he said.
He said it was “disappointing” that no ICU consultant was on duty again until 8am.
“A woman is dying in front of their eyes in the need of a consultant and there isn’t an ICU consultant,” said Mr Tansey.
Dr Boylan said there is a problem recruiting “quality consultants in our hospitals and there is a particular problem in intensive care units”.
Dr Boylan said women who survive HELLP syndrome - and 98pc do - had a 20pc chance of suffering pre-eclampsia in a subsequent pregnancy and a 5pc chance of suffering again from HELLP