Hospitals need to learn from the cases of Sally and Dhara to prevent future deaths
Analysis from the Irish Independent on 9 December 2014 on the death of Sally Rowlette.
The HSE’s only investigation into the death of Sally Rowlette did not identify the failures in the care she received. This is in direct contrast to the finding of Dr Peter Boylan, the independent expert witness at the coroner’s inquest into Sally’s death.
Last week, the jury at the coroner’s inquest into Sally’s death in Sligo Regional Hospital unanimously agreed a verdict of medical misadventure. Sally died on February 5, 2013 of a massive haemorrhage the day after giving birth to a girl, Sally junior. Her haemorrhage was caused by HELLP syndrome, a rare condition brought on by pre-eclampsia (high blood pressure) in pregnant women.
The HSE’s review of the care of Sally Rowlette, seen by the Irish Independent, had just one recommendation. It was that patients who develop HELLP syndrome “should be informed of the… risk… in subsequent pregnancies in order that they make fully informed family planning choice”.
Dr Boylan’s report said there should have been alarm bells at her regular hospital check-ups at 35 and 37 weeks given Sally’s history of HELLP syndrome, which put her at a higher risk of pre-eclampsia. He believes Sally should have been referred to her GP for daily blood tests or more regular hospital monitoring. This did not happen. Dr Boylan and another consultant obstetrician at the inquest both said they would have induced Sally at 35 or 37 weeks due to her rising blood pressure. This did not happen.
When Sally arrived at Sligo Regional Hospital in the early hours of February 4 with labour pains, she was noted to be “very distressed, vomiting and complaining of a headache”. She was examined and it was decided to carry out an emergency c-section. Dr Boylan’s assessment was that “Ms Rowlett represented a medical emergency requiring urgent intervention to control blood pressure” and “immediate senior medical attendance”.
At the inquest, her blood pressure reading was described as “off the wall”. Yet, it was 20 minutes before the junior doctor was called, 40 minutes until he arrived and 45 minutes until the appropriate medication was given.
During this time, her blood pressure was going up and her heart beat was slowing. Sally gave birth without complication, so a c-section was unnecessary and she was transferred to the Intensive Care Unit. There was no ICU consultant to care for her in her first four hours there. Critical blood tests were not taken for three hours, when her deterioration was noticed. Within six hours of arriving in ICU, it was noted her condition might be fatal. Within 20 hours, Sally was dead.
None of these lapses in Sally’s care were identified in the HSE review and there were no recommendations to learn from the clinical management of her case.
After a series of fatal incidents in our health system, there is now a much greater focus at the highest level in the HSE on patient safety and quality care. The independent enquiry into the death of Tanya McCabe in Our Lady of Lourdes Hospital in Drogheda in 2007 recommended that “the most important outcome following any adverse event and review is the process that promotes understanding to ensure that the organisation learns from the events and prevents recurrence”.
In rhetoric and procedurally the HSE is placing a significant emphasis on improving patient care through continuous learning environments and open disclosure. The HSE 2015 Service Plan has a 14-page appendix detailing their new ‘Quality and Patient Safety Enablement Programme’.
Three years before Sally died, Dhara Kivlehan died from HELLP syndrome in a Belfast hospital after giving birth to her first child and receiving treatment in Sligo Regional Hospital. Both Dhara Kivlehan and Sally Rowlette’s HSE reviews are remarkably similar, most notably in the absence of any identification of the poor care they received.
The fact that Sally died three years after Dhara is demonstration to the lack of the learning in the hospital from the previous incident.
Peter Boylan named the low number of consultant obstetricians as a contributory factor to Sally Rowlette’s poor care.
There is strong evidence that senior clinicians play a crucial role in patient outcomes. But there is also very strong evidence of the importance of how a hospital’s culture directly relates to patient outcomes.
It is now known that patients receive better quality care in hospitals where staff are valued and treated well, where they are encouraged to be open and learn from mistakes and where patients and their families are listened to.
The HSE reviews into the care received by these two women in Sligo Regional Hospital do not illustrate any learning from mistakes made. Michael Kivlehan and Sean Rowlett have done great service to the State by highlighting the tragic, unnecessary deaths of their wives. Their one wish is that no one else should go through what they are going through.
Surely the least the State could do is ensure that all adverse events, particularly those which are fatal, should be subject to robust, independent review.