The husband of 38-year-old woman who died after giving birth to their second child told reporters outside the steps of Castlebar Court House last Monday, “Two years ago was supposed to be Evelyn’s day, but this is Evelyn’s real day. The last two years have been difficult but we knew what happened and that eventually the truth would come out.” Mr Padraig Flanagan was speaking after the coroner’s inquest into the death of his wife Evelyn Flanagan (38 ) of Hollyhill, Ballyheane, Castlebar, on October 19, 2007 found that the cause of her death was “medical misadventure” following evidence from two independent witness from the UK, which was given at the inquest.
Mr John O’Dwyer, coroner for south Mayo, had adjourned the inquest last September to get outside expert evidence on the case following a request from Mr John Jordan. Consul for Mr Flanagan had asked for the expert evidence, following the evidence from Dr Fadel Bennani, the pathologist at Mayo General Hospital. Dr Bennani said he was 100 per cent certain that Mrs Flanagan died following an amniotic fluid embolism, which had entered Mrs Flanagan’s bloodstream through a tear in her uterus and eventually caused a clot in her lung.
Dr Kevin West, consultant pathologist with Leicester Royal Infirmary, held a different view from that of Dr Bennani; he told the inquest that it was his opinion that Mrs Flanagan died following post partum haemorrhage, following blooding and fluid administration. He also went on to state that amniotic fluid embolism could not be ruled out as a contributory factor in her death but he was unable to give a estimate of the contribution it had made.
Evidence was also given by Professor John Walker, consultant in obstetrics and gynaecology at the University of Leeds, who told the inquest that he was not convinced that AFE was the primary cause of Mrs Flanagan’s death, nor did he believe that haemorrhaging by itself caused it. He told the inquest that after reviewing the medical records he believes that Mrs Flanagan was given eight units more blood than she had lost and he could find nowhere in the notes a fluid balance chart that would show the amount of fluid Mrs Flanagan had lost and how much she had been given. From his reading of the records he believed that she was given 17 to 18 units of blood, which was eight more than she had lost, and eight litters of fluid more than she had lost. He went on to say that this fluid overload could cause cardiac failure, pulmonary oedema, coagulation defects, and an elevation of potassium and this could all lead to cardiac arrest. He told the inquest that fluid overload was a factor in her death but he would have expected Mrs Flanagan to survive it.
“She appeared to die from cardiopulmonary failure, secondary to fluid overload, cardiac dysfunction, pulmonary thrombosis and maybe amniotic fluid embolism,” he told the inquest.
Dr Irene Tchum, who also gave evidence, told the inquest that she had requested a fluid balance chart to be kept, but it had not been kept. “It should have been kept, there is no excuse for that,” she said.
Mr John O’Dwyer, coroner, told the jury they could find any one of three possible verdicts, they were death by natural causes, medical misadventure, or a narrative verdict. After just over half an hour of deliberation the jury returned a unanimous verdict of medical misadventure. Mr O’Dwyer sympathised with Mr Flanagan, his two daughters, and Evelyn’s family for their loss. He also sympathised with Dr Mohamed, Mrs Flanagan’s obstetrician, and the staff at Mayo General Hospital. Tony O’Connor, counsel for the HSE, also offered his sympathies to Mr Flanagan and his children and extended family.
