A verdict of medical misadventure was returned at the inquest of a woman who had to wait almost 40 minutes for a blood transfusion after she suffered severe bleeding following an emergency birth.
Nora Hyland (31) a Malaysian woman living at Charlotte Quay in Dublin 4, died on the operating table at the National Maternity Hospital (NMH), Holles Street, on February 13, 2012, within three hours of undergoing an emergency Caesarean-section to deliver her son, Frederick.
Dublin coroner Dr Brian Farrell found the cause of death was a cardiac arrest as a result of severe post-partum haemorrhage. However, he said that he was not able to say the delay in Mrs Hyland receiving blood was a "definite" risk factor in her death.
The inquest previously heard that a labelling error in the laboratory contributed to a 37-minute delay in Mrs Hyland receiving a blood transfusion.
No emergency supply units of O-negative, the universal blood type, were kept in operating theatres at the NMH.
The master of Holles Street, Dr Rhona Mahony gave evidence that she did not believe that Mrs Hyland had a heart attack as a result of hypovolemia - a drop in blood volume. Holles Street has since installed a fridge holding emergency blood units in theatre.
Mrs Hyland received the blood transfusion at 12.40am, 37 minutes after her treating physician first ordered it having realised she was losing blood. She had also undergone a laparotomy to stop the bleeding. She was initially stable but went into cardiac arrest at 1.05am and doctors battled to save her for over an hour before she was pronounced dead.
The final day of the inquest heard from the coroner's expert, Dr Michael O'Hare, consultant obstetrician and former chairman of the Institute of Obstetrics and Gynaecology at the Royal College of Physicians of Ireland. He said that Mrs Hyland's sudden deterioration "is, likely, on the balance of probability, to have been due to massive blood loss".
If the cardiac arrest had happened as a result of hypovolemia, Mrs Hyland would have been most vulnerable just prior to the transfusion, he said.
However, he conceded under questioning from the family's barrister that Mrs Hyland remained vulnerable post-transfusion and that had it been done earlier it may have reduced the challenge of the blood loss.