AIMS Ireland calls on the Minister of Health SImon Harris to initiate without further delay an Independent External Inquiry into the death of Malak Thawley at the National Maternity Hospital in May 2016 following routine surgery for an ectopic pregnancy.
Last month’s Public Inquest into Malak’s untimely death resulted in a verdict of medical misadventure, but several issues of public concern were raised in the evidence given. AIMS Ireland believe that many of these issues need to be addressed not as a matter of internal clinical practice but as part of a broader inquiry. The internal inquiry may well enable staff to initiate improved protocols and guidelines, and may have revealed information about drills associated with major obstetric haemorrhage in the hospital, but this case has raised many issues of public concern. In particular AIMS Ireland has received many concerned calls about the fact that a second year registrar was practicing without a senior consultant obstetrician on site. AIMS Ireland calls on the Minister to clarify what the situation is with respect to on site cover of maternity care both in terms of senior consultant obstetricians and also consultant anaesthetists.
Furthermore, external inquiries will have access to a much wider range and depth of material than an internal review, and in this sense they are able to draw broader conclusions. For example, the external enquiry into Port Laoise hospital revealed that there were issues with senior HSE management that needed to be resolved, something that the internal review did not uncover. An external review also carries greater weight in terms of public confidence. The public quite rightly in many cases, believes that internal reviews tend to reveal very little in terms of publicly accessible information, and offer less again in terms of boosting public confidence. For example the internal review into the death of Bimbo Onanuga at the Rotunda Hospital following an intra uterine death required questions to be put from the Dail floor in order to elucidate what the internal inquiry had found out. hardly transparent and hardly inspiring for those families who planned to birth there.
External inquiries also enable similar cases to be explored and evaluated. Not all cases of maternal death or poor care reach the media or reach the courts. Inquests into maternal deaths are currently not mandatory in Ireland, so only those that are heavily campaigned for will see the light of the Coroners Court. Often there are more cases in which the families are less media and legally savvy lurking in the background. External inquiries can unearth these and can often highlight repeated cases, which might have been prevented had an external inquiry been carried out earlier. An example here is in the on going Portuncula Hospital Maternity External Review in which other cases not originally under review have been brought to light.
Clinicians in the Maternity Services often bitterly state that they are constantly under fire from the media, and for the main part they provide a great service with limited capital and human resources, and so there is a resistance to any outside or external investigation, and it is as though such procedures are viewed as blame assignment exercises, however external reviews are not about assigning blame they are about learning from mistakes and ensuring that care is optimised and that families and babies in ireland receive the best possible evidence based safe care available.
This case also raised the issue of mandatory inquests for all maternal deaths in ireland. AIMS Ireland fully support Deputy Clare Daly’s in her efforts to ensure that in the amendment to the up coming Coroner’s Bill there will be provision for mandatory inquests into maternal deaths. Only by such inquests can the full facts com into the public domain, and can the families in question understand the circumstances by which their loved ones died.
Questions about 24 hours senior obstetric cover and supervision
Questions about the supply of blood products
Questions about the speed with which emergency treatment for MOH was carried out
Questions about the supply of surgical equipment (vascular clamps) and surgical staff (vascular surgeons)
Questions about why it took the hospital so long to apologise and why the Thawley’s solicitor stated “Obtaining an appropriate apology has been very difficult.”
Of course the biggest questions on many maternity user’s lips is “Would Malak have survived if the NMH were a co located hospital?” The answer is we will never know, but what we do know is that any tertiary referral maternity hospital that handles every level of risk should not be a stand alone unit. By its very nature it needs to be co located. However co location in and of itself does not guarantee improved outcomes. Savita died in a co located maternity hospital. What is vital are the governance procedures, and only an external inquiry will guarantee the most considered governance procedures resulting from this tragic case.
AIMS Ireland wishes to reiterate its heartfelt condolences to the family of Malak Thawley