Delays in recognising shock 'may have contributed' to Nayyab Tariq's death after childbirth

Nayyab Tariq died on March 22 last year, four hours after giving birth to a healthy baby girl, also called Nayyab.

Delays in recognising a young woman who had just given birth was in shock were a "key causal factor" to her death, an internal HSE review has found. 

The review into the death of Nayyab Tariq found her skin pallor was "initially less obvious" due to her ethnicity.

A verdict of medical misadventure was recorded on Wednesday by an inquest into the death of the young woman at Mayo University Hospital.

An apology from the hospital was read in court to her husband Ayaz Ul Hassan.

“We unreservedly apologise for any failings or shortfalls in the standard of care provided to both your late wife and to you at the hospital, including the poor communication and updates provided to you during the time that your wife was in the operating theatre,” the statement said.

“We understand that this apology cannot change or negate the depth of your loss but we wish to assure you that every single recommendation and issue that arose in relation to the standard of care provided is being addressed in full by the hospital.” 

Ms Tariq died on March 22 last year, four hours after giving birth to a healthy baby girl, also called Nayyab. Her husband was in the theatre with her, holding her hand to the end.

The unpublished review of care, seen by the Irish Examiner, states: “The review panel found that there were systems of care/service issues which may have contributed to Mrs A’s death. Earlier recognition and intervention may have altered the outcome in this case.” 

The review and inquest found multiple factors leading to Ms Tariq’s death. 

The HSE review and inquest found multiple factors leading to Ms Tariq’s death.

However, the review team, chaired by Coombe hospital obstetrician Dr Carmen Regan, found a “key causal factor” was the “delay in recognition and treatment of shock due to haemorrhage”. 

Earlier this week, the inquest heard changes in skin colour can be an indicator of shock.

The hospital review found: “Skin pallor was initially less obvious due to ethnicity” and notes two hours after giving birth Ms Tariq was recorded as “ashen”. It found “blood was commenced over 90 minutes after the first signs of shock”. 

The review could not be submitted to the inquest under Mayo coroner Patrick O’Connor.

However in giving his verdict, he said he hoped the recommendations in the review were “actively followed and implemented”.

The review notes “this case revolves around the management of shock”.

The recommendations include a call for staff to follow “local and national procedures protocols and guidelines in regard to post-partum haemorrhage and retained placenta”. 

Management at the hospital “must ensure that vital signs are tracked and recorded appropriately” and “clear escalation processes are in place”.

The review recommends the hospital install “a blood gas analyser with haemoglobin measurement function” in the delivery suite. It refers to “misleading results” from existing equipment and notes a key device did not have “regular maintenance and calibration”.

It found “inadequate communication” with Mr Ul Hassan while his wife was in theatre, and recommends “a senior midwife or nurse on duty” act as family liaison.

An “electronic anaesthesia record” should be maintained and management was advised to “review the communications processes between labour ward and theatre”.