A DAD who lost his wife a day after she gave birth to their fourth child broke down in tears as a jury found she died from medical misadventure.
Sean Rowlette (39), from Dromore West, Co Sligo, was hugged by relatives and friends as the jury at Sligo Courthouse made a number of recommendations to the HSE.
His wife Sally (36), died on February 5 last year, a day after giving birth to baby Sally. She had a brain haemorrhage after suffering the blood pressure illness HELLP syndrome.
The three-day inquest heard that a consultant obstetrician had failed to bring her into hospital for an induced labour two weeks earlier, even though she had suffered from the same illness on the birth of her second child in 2007.
The jury of five men and four women were also told that an intensive care unit consultant left the hospital for almost four hours, leaving Sally's care largely in the hands of nurses. She suffered the haemorrhage during this time.
Among the jury's recommendations was that a senior consultant should follow through in such medical emergencies in the future. They also recommended that internal hospital reviews should be more open and results shared with staff.
"I found out a lot of things that I never knew about," said Mr Rowlette, who quit his job as an engineer to raise Leanne (9), Abbie (7), Joseph (4) and 21-month-old Sally.
"Christmas will be tough again, but it's tough every night. The kids go to bed and you turn the key and you're sitting alone.
"My aim has been to make sure no other family goes through what we're going through, that lessons are learned so women going into hospital don't end up like Sally."
Solicitor Roger Murray said it was "ridiculous" that two consultants involved in the case were not at the inquest, having both left Sligo Hospital.
"One consultant left his post for more than four hours at a critical time," he said.
"The other, Dr Murshid Ismail, who was Sally's obstetrician, missed key opportunities to bring her into hospital to have the pregnancy induced before this illness took hold.
"We are pursuing ways of finding him and we have instructions to begin legal proceedings against the HSE."
Earlier yesterday Ireland's leading obstetrician Dr Peter Boylan, from the National Maternity Hospital, said Dr Ismail should have known from Sally's medical records that she had suffered from HELLP syndrome in 2007.
When on two occasions her blood pressure was raised, Dr Ismail should have referred her to her GP for further testing within days.
The jury said patients suffering from similar symptoms in previous pregnancies should be advised of the possible dangers of further pregnancies.