Heartbroken Carlow family calls for inquiry into maternity services at St Luke's Hospital

The family of a Carlow woman who bled to death following a massive post partum haemorrhage at St Luke’s Hospital in Kilkenny are calling for an inquiry into maternity services at the hospital.

Tracey Campbell Fitzpatrick from Nurney, Co Carlow bled to death at St Luke’s Hospital in March 2016 following repeated phone calls to an on-call consultant to attend to her. David McMurray was on call in the early hours of March 28, 2016 when he was called on three occasions by a senior midwife.

David McMurray, who was a locum consultant at St Luke’s Hospital at the time was found guilty of professional misconduct and poor professional performance by a fitness to practise (FTP) hearing of the Medical Council in February of this year. David McMurray admitted a charge of professional misconduct over his failure to attend to Ms Campbell Fitzpatrick in a sufficiently timely manner when he knew her clinical condition required his attendance at the hospital.

The hearing heard it took more than 40 minutes for Dr McMurray to arrive at St Luke’s after he was alerted to the need to bring the patient to theatre, to deal with extensive postpartum bleeding, despite living just five to eight minutes away from the hospital.

The first phone call was made at 1.37am and David McMurray did not attend the hospital until 2.20am. Tracey was pronounced dead at 3.45am on March 28, 2016.

Grief

Tracey (36) died within three hours of giving birth to her second son Max. More than seven years after Tracey’s death the pain and grief that her family carry is palpable, but even stronger than that is their love for her and their unwavering courage in taking on the HSE and St Luke’s Hospital to seek answers in relation to Tracey’s death.

Her family want to know what the midwife said to David McMurray during the three phone calls and why it took 43 minutes for him to attend the hospital. They have also requested that a new inquest be held into Tracey’s death and do not agree with the findings of death by natural causes from the original inquest.

“What was natural about a healthy young woman going into hospital to have a baby and coming out in a coffin?” said Tracey’s father, James.

Correspondence from the Irish Medical Council to the Campbell family said that they had received correspondence from the Irish Nurses and Midwives Organisation which stated that the midwife in question ‘was not in a position to provide any information to the Preliminary Proceedings Committee in relation to the matter’. The family want to know why this is.

“The awful truth of this is that Dr Mc Murray could have saved Tracey’s life if he responded to the phone calls asking for assistance. Instead he did not come into the hospital until it was much too late and by doing so he allowed Tracey to bleed to death, a death that could and should have been avoided,” said Tracey’s father, James who has campaigned tirelessly for the truth into the circumstances surrounding his daughter’s death along with the rest of her family.

In 2021, the HSE admitted liability in Ms Campbell Fitzpatrick’s High Court case and both the HSE and St Luke’s Hospital apologised unreservedly for the failings in her care.

“As a family we are calling on the Minister for Health Stephen Donnelly to carry out a public inquiry into the maternity services at St Luke’s Hospital following a series of adverse findings against consultants who worked at the hospital’s maternity unit in recent years.

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“We want to share our story and our pain and to raise awareness about what has gone on. It has been absolutely horrendous and we still are looking for answers. David McMurray never explained why he didn’t come when he was called the first time. If he had he could have saved Tracey by carrying out emergency surgery, we have never got the answers we wanted from David McMurray or the senior midwife who rang him that night.

“There is a legacy of failures at the maternity unit of St Luke’s Hospital and we are calling on the Minister to carry out an inquiry —we need something to restore confidence for the people who rely on the hospital,” he added.

The family’s call for an inquiry comes in the wake of a number of other incidents relating to women’s healthcare. 

Three other consultants in gynaecology and obstetrics have come under scrutiny at St Luke’s Hospital in recent years.

Professor Ray O’Sullivan was placed on administrative leave on full pay in August 2019 by his employer, the HSE, after complaints were made against him by other members of staff. He allegedly carried out unauthorised and unapproved actions and procedures on five female patients in September 2018.

None of the patients were informed about the research or consented to the procedure, nor were they aware of it until afterwards, it is claimed.

The women were not physically harmed by the procedures but on learning what happened were allegedly psychologically injured.

Prof O’Sullivan has strongly rejected all allegations of wrongdoing against him. The HSE appealed a ruling by the Court of Appeal last year that Prof O’Sullivan, who denies all wrongdoing, was entitled to return to his job.

The Supreme Court has ruled that the HSE acted fairly and reasonably when it suspended and recommended that consultant gynaecologist Professor Ray O'Sullivan be dismissed from his former job at St Luke's Hospital in Kilkenny.

Failures

In September 2021 Dr Trevor Hayes, the clinical director for obstetric and gynaecological services at St Luke’s, admitted that there were failures by St Luke’s General Hospital in Kilkenny in the care of a baby boy who died five days after an ‘acute event’ at his birth as well as the treatment of his mother, who was 11 days overdue.

Dr Hayes offered an apology on behalf of the hospital to the boy’s mother and her family, as he appeared before an inquest into the baby’s death.

In 2018 a fitness to practice inquiry found Dr Trevor Hayes guilty of poor professional performance in relation to several allegations made against him. A case was taken against the Kilkenny-based consultant obstetrician and gynaecologist regarding the treatment of his patient between 2009 and 2014.
The patient died as a result of bladder cancer in 2015.

Dr Hayes has admitted to poor professional performance regarding failing to adequately investigate the patient’s complaint of haematuria between 2012 and 2014, and failing to refer her to urology for review.

When contacted for comment, the Ireland East Hospital Group said it could not comment on individual patient cases. In a statement issued, it said the Serious Incident Management Team (SIMT) in St Luke’s General Hospital with the Ireland East Hospital Group review all maternal deaths. All maternal death reviews are carried out in line with the HSE Incident Management Framework and are reported to the HSE and NWIHP (National Womens and Infants Health Programme).

“In 2019 a HIQA report identified several issues with the Department of Obstetrics and Gynaecology in St Luke’s General Hospital Carlow/Kilkenny,” said the statement.

“Recommendations were made and significant work improvements have been made in the delivery of care to women in St Luke’s General Hospitals maternity unit. Hospital management and the Ireland East Hospital Group have worked closely with the maternity unit to address all issues raised through consultation and reviews which were undertaken with staff and patients with immediate actions taken to implement a robust structure to provide safety assurance for all patients.

“Significant steps have been taken to improve all aspects of maternity/obstetric care with the addition of further specialist clinical staff to the service.

QUALITY CARE

“St Luke’s General Hospital, Kilkenny endeavours to provide the highest standard of care to all women who attend at the maternity unit. The hospital, along with the Ireland East Hospital Group are committed to continuously monitoring and working with the hospital and staff, listening to patients to ensure that safe, quality care is being provided to all patients attending the hospital.”

All maternity hospitals and units, which includes St Luke’s General Hospital publish their safety statements on a monthly basis.

The IEHG says that all national maternity data (mortality and morbidity) is monitored.