HSE Issues Apology Amidst Inquest into Tatenda Mukwata’s Death After Childbirth
Dublin – A doctor’s emotional breakdown, an apology from the Health Service Executive (HSE), and nurses expressing concerns about a drop in blood pressure have marked the ongoing inquest of Tatenda Mukwata’s into the tragic death, a 35-year-old Zimbabwean woman who passed away shortly after giving birth at University Hospital Kerry last year.
Tatenda died at 2 am on April 21, 2022, just six hours after delivering her fourth daughter, Eva, via Caesarean section. She had been living with HIV since 2009 and regularly sought care from an HIV specialist at CUH, faithfully adhering to her medication regimen.
During the opening day of the inquest in August, a pathologist revealed that Tatenda had died from hemorrhage and shock.
At the recent resumed inquest on Monday, HSE senior counsel John Lucey read an apology on behalf of Mary Fitzgerald, the general manager of UHK. The apology acknowledged the lapses in Tatenda’s care at the hospital on April 20th and 21st, 2022, admitting that these failures should not have occurred and that earlier intervention might have prevented her tragic demise.
The HSE expressed its commitment to ensuring lessons are learned from the incident, with an external review nearing completion. The hospital extended its deepest apologies and heartfelt condolences to Tatenda’s family, recognizing the immense grief, stress, trauma, and suffering they have endured due to her death.
On Tuesday, a South African obstetrician gynecologist named Dr. Fahad Hendricks, who had been practicing in Ireland for only three months at the time of Tatenda’s passing, broke down during the inquest.
Overwhelmed with emotion, Dr. Hendricks, who had been assigned to the high-risk ante-natal clinic and was working his third consecutive 24-hour shift that week, requested to meet Tatenda’s family.
He had formed a positive rapport with Tatenda, sharing their Southern African background. While reading his deposition, Dr. Hendricks struggled to contain his emotions.
Dr. Hendricks noted that Tatenda’s Caesarean section had been uncomplicated, with normal blood loss and no signs of hemorrhage.
However, at 22:55, concerned nurses paged him after observing Tatenda’s low pallor and suspected septic shock.
Dr. Hendricks investigated the possibility of a surgical bleed but found no evidence or indications thereof. The wound dressing was clean, there was no vaginal bleeding, and the uterus was contracting.
Recalling his training in South Africa, where 30 percent of women in ante-natal clinics are HIV positive and immune-suppressed, Dr. Hendricks admitted that he was unaware of the drop in Tatenda’s hemoglobin levels.
In response to Dr. John O’Mahony, the senior counsel representing the Mukwata family, Dr. Hendricks honestly admitted that he had not checked Tatenda’s hemoglobin levels.
However, had he been aware of the drop, he would likely have repeated the blood sample. This would have reinforced his suspicion of intra-abdominal bleeding, prompting him to take steps to bring Tatenda to the operating theater for further intervention.
Dr. Hendricks’ request to meet Tatenda’s family evoked emotional scenes in the courtroom. He wept and sought comfort at the back of the room as the jury went on their lunch break.
On the third day of Tatenda’s inquest, it was revealed that the staff at University Hospital Kerry had performed four C-sections on the night she passed away, making it a challenging shift for the nurses and clinicians involved in her care.