Inquest reveals new mum Rosa Keenan went from labour pains to death at Daisy Hill Hospital in under 12 hours following caesarean

Rosa Agnes Anne Keenan of Kilkeel (nee Murphy) was 37 when she died at Daisy Hill Hospital in Newry after a Ccaesarean section.

A wide-ranging investigation into her death has concluded that she died of “refractory acidaemia” (a stubbornly low blood pH) following “post-partum haemorrhage” (heavy bleeding after birth) with asthma listed as a second factor (slight inflammation of her airways was found in the post-mortem).

A coroner found that whilst by-and-large the care she got was “appropriate”, there was a handful of shortcomings.

FINAL 12 HOURS:

Mrs Keenan had previously experienced two “normal deliveries”, giving her a daughter (Katie) and son (Caolum).

Her death came on March 5, 2018, two months and 10 days before the due date for child number three.

That day, she rang the hospital at 8.20am to say strong contractions were underway.

An hour later she was in the delivery suite, and medics found the baby was in a “transverse breech, with the baby positioned bottom first”.

She was given drugs to increase contractions and told to begin pushing.

But by 10.48am, medics were so concerned about the way labour was shaping up that they decided a C-Section was needed.

At 10.55am she was taken to the operating theatre, and at 11.07am baby Oisin was delivered by Caesarean.

Mrs Keenan was then taken to the recovery suite; she had lost a litre or so of blood.

Then at around 2.30pm her heart rate jumped to 150bpm (a normal rest rate is 60 to 100).

It rose yet further, and she began losing more blood.

What followed was an intensive few hours as medics fought to get her back to normal.

Upon realising she needed to go back into theatre, husband Stephen held her hand and told her “everything would be ok” whilst she “smiled back at him and said she loved him and that she would see him later”.

She kept bleeding, ultimately losing around five litres – basically the entire average amount that a human being holds – whilst doctors attempted to replenish the losses.

She went into cardiac arrest, and efforts to revive her failed.

She was pronounced dead at 8.09pm – 11 hours and 49 minutes after she first picked up the phone to the hospital.

The details in this report all come from the coroner’s written findings, set out on March 16 and subsequently issued to the News Letter.

WHO WAS MRS KEENAN?:

Widower Mr Keenan told the inquest that his late wife had been a “real family woman”, with a particular passion for football.

The findings state that “when her daughter Katie joined the local team, the deceased never missed a day watching her”.

She was also “a big fan of country music, especially Nathan Carter – to the extent that Mr Keenan arranged for him to play at their wedding as a surprise for her”.

Summing up, her widower dubbed her “a fantastic woman, full of life” whom they miss every day.

“None of us have really come to terms with Rosa’s passing,” he told the inquest.

During the inquest, consultant obstetrician Dr Lucy Kean had described her as “a young fit lady”.

WIDOWER RAISED CONCERNS:

The coroner’s findings run to a mammoth 38 pages, packed with dense testimony from medical experts.

In them, coroner Maria Dougan said her widower had “raised a number of issues in relation to the deceased’s care and treatment” – in particular that they were clear from the outset they wanted a C-Section, but instead medics had insisted on trying a normal birth first.

Gynaecologist Dr Peter Lenehan told the inquest a regular birth “is much safer for the woman” and it had been “appropriate” to pursue it, despite her plans to have a Caesarean – and the coroner agreed.

Another key issue Mr Keenan raised was “the apparent disparity between the volume of blood which the deceased lost and the amount of fluids replenished”.

Dr Lenehan gave evidence that “the suboptimal replacement of fluids was not the main cause, but a contributory cause leading to the death”.

The coroner ultimately made a finding that while “an earlier and more substantial fluid resuscitation was required... on balance, the total estimated blood loss was reasonably matched by the input of blood and clear fluid”.

Mr Keenan’s further criticisms included that “there appeared to be no consideration given to a hysterectomy (removal of the womb)”, for which Mrs Keenan’s consent had been given.

Janet Acheson, consultant obstetrician and gynaecologist, told the inquest that “a hysterectomy is a major operation that can cause more bleeding and trauma and it has to be justified”.

Given the intense bleeding, she declared herself “duty-bound” to stop it as soon as possible, which she did within 20 minutes without a hysterectomy – adding that to have gone ahead with the procedure could have taken about 30 to 45 minutes.

When it comes to why her blood had become acidified, Dr Kean said the likely contributing cause “has got to be the Carboprost” – a drug also known as Haemabate, which is given to patients to stop post-partum bleeds.

The drug can have side-effects on people who have asthma, and whilst doctors can (and do) give it to asthma sufferers, caution is generally advised.

The coroner concluded “the experts accepted that the administration of Haemabate was reasonable in this case,” given the urgent need to stem her massive blood loss.

‘LESSONS HAVE BEEN LEARNED’ SAYS CORONER:

Much of the care Mrs Keenan got was deemed “appropriate” by the coroner.

But she did find a handful of failings too.

As a result, there have been “a number of lessons learned”.

For instance, the coroner found that “the evidence suggests that the fluid balance in the deceased’s notes and records was not completed in accordance with good practice”.

She also found “insufficient coagulation tests were carried out, and earlier results may have been a further indicator of the deceased’s progressive deterioration... [however] on balance, I find that this would not have made a difference to the overall outcome”.

Questions were also raised during the inquest about which medics had overall charge of the crisis situation.

The coroner concluded there was a “need for a leader to be appointed in an emergency situation, whose responsibility is to show overall management and awareness of a situation” and “this training is to be embedded” in an annual course.

Other lessons include altering the way blood loss is recorded.

Absorbent swabs are now weighed, rather than medics merely estimating lost fluid – with the result that the Southern Trust is “currently the only trust in Northern Ireland that measures blood loss rather than estimating blood loss”.

In addition, “regular post-partum haemorrhage emergency drills are now carried out twice yearly”.

HELP MAY BE AT HAND:

NI Direct refer people who have been bereaved to a support service called Cruse, based in Belfast.

It describes itself as a helpline ”run by trained bereavement volunteers, who offer emotional support to anyone affected by grief”.

They can be contacted for free at this number:

0808 808 1677

Its opening hours are as follows:

Monday: 9.30am-5pm

Tuesday: 9.30am-8pm

Wednesday: 9.30am-8pm

Thursday: 9.30am-8pm

Friday: 9.30am-5pm

Saturday and Sunday: 10am -2pm

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