Medical misadventure is a sort of a sad shrug of a verdict.
That was how the death of 35-year-old Sally Rowlette was described at the end of the inquest: medical misadventure.
She looks so healthy in photographs that one wants to believe that “medical misadventure” in this instance meant some extraordinary event that couldn’t have been prevented.
One wants to think the same about the phrase used by Dr Peter Boylan, former Master of the National Maternity Hospital, who, giving evidence at the inquest, spoke of “a broad systems failure”.
“A broad systems failure” sounds like short-circuiting within an electrical system.
Except that a maternity hospital is not an electrical system. It is a place of excitement and pressure, of skill and of genius. A part of family life filled with terror and triumph.
But, above all, it is a place where professional medics deal with the perfectly normal procedure of childbirth and where they also, less frequently, deal with the perfect storm of abnormal factors that characterise a minority of births.
Or fail to deal with that storm, as was the case during Sally Rowlette’s last day and final weeks.
This is where “medical misadventure” fails to convey the truth of what happened to one young mother, and Peter Boylan’s “broad systems failure” comes only marginally closer to delivering the tragic truth.
This truth is one of individuals working at the coal face of medicine failing to learn from previous mistakes, failing to respond to self-evident need and failing to take sufficient cognisance of an individual patient’s prior form in this context.
Sally Rowlette, giving birth to an earlier baby, had suffered from a syndrome that should halt any medical practitioner in their tracks.
Any mother in the final weeks of pregnancy who has suffered HELLP Syndrome in the past might as well have a warning sign tattooed across their forehead.
Peter Boylan indicated that if Mrs Rowlette had been his patient, she’d have been in hospital two weeks earlier, being induced.
It wasn’t just that she herself had showed evidence of this syndrome on a previous birth, it’s that clinical experience of this issue is substantial. No surprise. Just failure to learn.
On top of failure to learn were piled one complicating circumstance after another.
The ICU consultant who went home leaving a critically ill patient in the hospital, tended to by nurses, not specialist consultants with experience in this kind of case.
Sally Rowlette’s blood pressure rocketed, her brain haemorrhaged. She died, leaving a husband to weep in court and children without a mum.
“Every night the kids go to bed and you turn the key on the door and you’re sitting there alone,” Sean Rowlette said.
“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.”
We’re proud that Ireland is one of the safest places in the world in which to deliver a baby.
The recurring verdict of “death by medical misadventure” puts a large question mark over that pride.