The jury at the inquest into a maternal death in Co Kerry in April 2022 has returned a unanimous verdict of medical misadventure.
Tatenda Mukwata (34), late of Atlantic Lodge in Kenmare, died after giving birth to her fourth child.
The jury found she died at University Hospital Kerry Tralee on April 21st, 2022.
“This was probably preventable. There was a misdiagnoses followed by a failure to investigate other possible differential misdiagnoses”, the jury said in its findings.
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The cause was a catastrophic haemhorrage and shock due to uterine arterial malformation following a Caesarean section.
The Tralee jury made seven recommendations including that clinicians need to “heed nurses concerns” and “investigate all likely causes of diagnoses”.
It also said “staff should not be required to work excessive hours on health and safety grounds” and an emergency response team in the maternity unit should be established, with proper training and education on haemhorrage policies.
It also recommended “an electronic record system be brought back in all sections in UHK, the southwest hospital group and HSE network, with appropriate cyber network protection.”
Routine early post-partum blood tests for haemoglobin should also be introduced, it said.
Sympathy was extended to the family by all concerned and the jury commended for its attentiveness.
