DUBLIN. – A doctor breaking down, the Health Service Executive issuing an apology and nurses raising concern over the drop in blood pressure.
It has been a mixed bag of emotions at the inquest of the death of a 35-year-old Zimbabwean, Tatenda Mukwata, who died soon after giving birth at the University Hospital Kerry last year.
She died at 2am on April 21, 2022, after giving birth six hours earlier to her fourth daughter, Eva, who was delivered by Caesarean section.
Tatenda had been HIV positive since 2009, and she would attend an HIV specialist in CUH and always took her medication.
A pathologist told the opening day of the inquest in August that Tatenda had died of haemorrhage and shock.
In its apology at the outset of the resumed inquest on Monday, HSE senior counsel John Lucey read an apology signed by Mary Fitzgerald, general manager of UHK, “for the failings of care afforded to Tatenda at this hospital on 20th and 21st April, 2022.
“We fully accept that these failings should not have happened, and that earlier intervention would probably have prevented Tatenda’s death.
“An external review of the matter is nearing completion and as a hospital we will endeavour to ensure lessons are learned.
“We are deeply sorry that you have suffered the tragic loss of Tatenda. We wish to apologise to you unreservedly and offer our heartfelt condolences. We acknowledge the grief, stress, trauma, and suffering that you and your family continue to endure as a result of Tatenda’s death, for which we are truly sorry.”
A South African obstetrician gynaecologist who had been working in Ireland for just three months at the time Tatenda died, broke down at her inquest on Tuesday, asking if he could meet her family.
Dr Fahad Hendricks was assigned to the high-risk ante-natal clinic and was working his third 24-hour shift in less than a week on April 20.
At 17.30 he went to meet Tatenda, with whom he had “a good rapport”.
He was excited to see her as both were from Southern Africa, Dr Hendricks said, breaking down and pausing in reading his deposition.
Tatenda’s Caesarian had been “uncomplicated” and there was normal blood loss and no haemorrhage.
At 22.55, paged by concerned nurses, he noticed her low pallor and suspected septic shock.
He had thought there might be a surgical bleed but found no evidence and nothing to indicate it.
The wound dressing was clean, there was no v*****l bleeding and the uterus was contracting.
“I trained in South Africa, 30 percent of women in ante-natal clinics are HIV positive, immuno-suppressed,” he said.
He was not aware of the drop in haemoglobin.
“In all honesty, I did not check,” Hendricks replied to Dr John O’Mahony, SC, for the Mukwata family.
But had he been aware of the drop, he probably would have repeated the blood sample, and his suspicion of intra-abdominal bleeding strengthened and he would probably have taken steps to have her taken to theatre for operation, he told the inquest.
There were emotional scenes as Dr Hendricks asked to meet the family of Tatenda and he was crying and being comforted at the back of the courtroom as the jury left for their lunch break.
The third day of Tatenda’s inquest heard that staff at UHK had carried out four C-sections on the night she died, in a “challenging shift” for nurses and clinicians. – Irish Times/Irish Examiner.