THE jury in Dublin Coroner's Court found yesterday that a woman who died of internal bleeding after a routine hysterectomy died as a result of "misadventure".
The jury agreed with the pathologist that the 39-year-old mother-of-two died from "haemorrhagic shock due to intra-abdominal haemorrhage from the pelvic operative site following hysterectomy and vaginal for uterine prolapse" in the National Maternity Hospital, Holles Street.
The coroner, Dr Brian Farrell, said it Was "clear that haemorrhage occurred over a number of hours and we cannot be more clear than that".
Mrs Marian Conlan, of Heatherview Lawns, Tallaght, died around 5.30 a.m. on January 13th, 1995. She had entered the theatre for her operation at 5 p.m. the previous day.
Dr Michael Geary, the registrar who carried out the operation under the supervision of consultant obstetrician, Dr Reginald Jackson, said the operation had been considered successful.
"At the end of the operation, Mrs Conlon was bone dry."
At around 8.30 p.me saw Mrs Conlon in the ward and found her pale and feeling very weak. He checked and found her blood pressure "normal", pulse strong. At the forefront of his mind was the possibility that she might be bleeding internally, but there was no clinical evidence that this was the case, he said.
He and the registrar anaesthetist, Dr M. El-Shami, agreed the patient should be given a blood transfusion.
He examined Mrs Conlon again around midnight. At around 2 a.m. he was called to the ward and found the patient seriously ill. "Literally before our eyes Mrs Conlon had a cardio/ respiratory arrest."
At 5.3Oa.m. Mrs Conlon's abdomen "literally ballooned up" and about 30 to 60 seconds later she died.
"She was a lovely woman, fit and well, in the prime of her life, come in for a supposedly simple operation." The typical signs indicating internal bleeding "were not there", Dr Geary said.
