High Court dismisses claim for adjustment disorder caused by hospital management of postpartum hemorrhage.

THE HIGH COURT Record No. 2021/126P BETWEEN:

VIRGINIA GIMENEZ PEREZ

PLAINTIFF

AND

COOMBE WOMEN AND INFANTS UNIVERSITY HOSPITAL AND THE HEALTH SERVICE EXECUTIVE

DEFENDANTS

Judgment of Ms. Justice Emily Egan delivered on the 8th day of July 2025

Introduction ............................................................................................3 Chronology as per the medical records ...................................................4 The oral evidence ....................................................................................8 Plaintiff’s factual evidence ...................................................................... 8 Plaintiff’s expert evidence .................................................................... 10 Plaintiff’s obstetric evidence: Dr. Ashe ................................................ 10 The Coombe management of labour and primary PPH......................... 10 Expectant management of the third stage of labour ........................ 11 Lack of consent to ARM .............................................................. 11 No epidural............................................................................... 12 “Placenta appears complete” ....................................................... 12 Management of the PPH.............................................................. 12 The MRH management of secondary PPH .......................................... 14 Admission on 04.11.19 ............................................................... 14 Emergency Department on 17.11.19 ............................................ 15

26.11.19 .................................................................................. 15

Plaintiff’s midwifery evidence: Ms. Coleman ......................................... 16 The Coombe: management of labour and primary PPH ....................... 16 ARM ........................................................................................ 16 Epidural ................................................................................... 17 Expectant/Active Management of the third stage ............................ 17 “Placenta appears complete” ....................................................... 17

01.25 ...................................................................................... 17

02.00 ...................................................................................... 18 Gush at 03.15 and 03.25 ............................................................ 19 Post Natal Ward ........................................................................ 19 Plaintiff’s pyschiatric evidence: Prof. Thakore ....................................... 20 Defendant’s factual evidence ................................................................ 20 Nurse Wright .................................................................................. 20 Dr. O’Higgins ................................................................................. 22 Dr. Maher...................................................................................... 23 Defendant’s expert evidence ................................................................ 24 Defendant’s obstetric evidence:

Dr. Lenehan ....................................... 24 The Coombe ................................................................................ 24 The MRH ..................................................................................... 26 Defendant’s Midwifery evidence: Ms. Hanrahan .................................... 27 Legal principles relating to the standard of care ................................... 28 Application of legal principles ............................................................... 31 The Coombe: management of labour and primary PPH ............................. 31 Consent to ARM .............................................................................. 31 Standard of approach .................................................................... 31 Did the Coombe comply with the standard of approach as regards consent to ARM? ...................................................................................... 31 Request for epidural ........................................................................ 32 Standard of approach .................................................................... 32 Did the Coombe comply with the standard of approach as regards the request for epidural? ..................................................................... 32 Expectant/active management of the third stage .................................. 33 Standard of approach. ................................................................... 33 Did the Coombe comply with the standard of approach as regards active management of the third stage ....................................................... 33 Failure to recognise that the placenta was incomplete at delivery ............ 33 Standard of approach .................................................................... 33 Did the Coombe comply with the standard of approach as regards the examination of the placenta? .......................................................... 33

Blood loss events ............................................................................ 34 Standard of approach .................................................................... 34 Did the Coombe comply with the standard of approach in its response to the plaintiff’s blood loss events?...................................................... 35 Blood loss event at 01.25 ........................................................... 35 Blood loss event at 02.00 ........................................................... 36 Blood loss events at 03.15 and 03.25 ........................................... 38 Summary of conclusions in relation to blood loss events ..................... 38 Overall conclusion in relation to the management of the plaintiff at the Coombe ......................................................................................... 39 The MRH: management of secondary PPH .............................................. 39 Standard of approach: conservative or surgical management ................. 39 Did the MRH comply with the standard of approach in its management of the plaintiff? ........................................................................................ 40

Conclusion ............................................................................................ 42

INTRODUCTION

1. Blood loss is a common occurrence in the labour ward. In particular, the delivery of the placenta is a time of inevitable bleed. However, if blood loss is excessive, it is classified as a post-partum haemorrhage (“PPH”). A primary cause of PPH is incomplete delivery of the placenta which prevents the uterus from contracting, which is necessary to stem bleeding in the uterine wall following placental separation. This is known as retained products of conception (“RPOC”).

2. The plaintiff alleges that the Coombe Women and University Hospital (“the Coombe”) failed to properly diagnose and treat her primary post-partum haemorrhage (“primary PPH”) after the birth of her second child. Primary PPH is bleeding from the genital tract of more than 500 mls in the first 24 hours following delivery. It is now common case that the cause of this PPH was RPOC. Separately, the plaintiff alleges that the Midland Regional Hospital, Portlaoise, (“MRH”) also failed to make a timely diagnosis of secondary post-partum haemorrhage (“secondary PPH”) due to RPOC. Secondary PPH is abnormal bleeding between 24 hours and twelve weeks following vaginal delivery. It can be caused by RPOC, but also by uterine infection. The plaintiff’s case is that as a result of the failure of the Coombe and the MRH to diagnose RPOC, she continued to bleed for 6 weeks after her delivery until a surgical evacuation of the RPOC (“ERPC”) was finally performed on 04.12.19.

CHRONOLOGY AS PER THE MEDICAL RECORDS

3. At 16.10 on 16.10.19, the plaintiff presented to the Coombe at 39 weeks plus 5 days gestation. Labour was established by 23.24 and the plaintiff was transferred to the labour ward. She requested an epidural, which she maintains she was denied.

4. At 00.22 the contemporaneous midwifery notes (“the continuation notes”), record a vaginal examination (“VE”) with consent, to assess progress; the plaintiff’s cervix was eight centimetres dilated and her membranes were intact. At 00.30 the continuation notes record an artificial rupture of the membranes (ARM), with clear liquor draining. The notes do not record consent for this ARM, which the plaintiff maintains was carried out without her consent.

5. At 00.45, the plaintiff’s cervix was fully dilated. At 01.03, baby Mia was born in good condition by spontaneous vaginal delivery.

6. There is controversy as to whether the third stage of labour, i.e. the delivery of the placenta, was managed expectantly or actively. Expectant management promotes observation for signs of placental separation from the womb and eventual natural delivery of the placenta. Although regarded as more physiological, expectant management carries a higher risk of PPH and is only undertaken in low-risk labours, on request of the mother. Under active management, oxytocin i.e. syntocinon is administered intramuscularly to promote uterine contractions and facilitate the separation of the placenta from the uterine wall. The placenta is then delivered using controlled cord traction. This technique significantly reduces the risk of PPH.

7. The continuation notes do not expressly record active management of the third stage of labour. They do however record that the placenta was delivered with controlled cord traction at 01.25 and the typed labour summary records both active management and intramuscular syntocinon (albeit that the timing of this medication is not specified).

8. The continuation notes document that the placenta was checked by the midwife (Nurse Sylvia Wright), after delivery and that it “appears complete”. When checking a placenta, it is usual practice to examine the lobes of the placenta, look for abnormalities such as unusual vessels, check the insertion of the cord and the number of cord vessels and examine the two layers of membranes for completeness. It is common case that it is very difficult to out-rule the possibility that a small piece of placenta is missing. It is not per se negligent to conclude that a placenta “appears complete” even if this transpires not to be the case.

9. On delivery of the placenta at 01.25 there were some “clots at the same time”. Estimated blood loss was 300 mls and an IV infusion of syntocinon was commenced to promote uterine contraction. When blood loss is estimated rather than measured, it will often be underestimated. However, it is common case that, at the time of this delivery, it was standard practice to estimate rather than measure blood loss, save in cases of concern.

10. At 02.00 a PPH of 340 mls was measured (as opposed to estimated) and clots were expelled. The continuation notes record that the uterus was well contracted, that bleeding had settled and that the plaintiff was asymptomatic. A second IV infusion of syntocinon was commenced. At this time, Dr. Chavez, Senior House Officer, was in the room suturing the plaintiff’s perineal tear and her clinical note confirms that “haemostasis was achieved” (meaning that bleeding had ceased). The continuation notes record two separate observations of the plaintiff’s BP (“BP”) over this period, 116/66, with a heart rate of 80 bpm and 116/66, with a heart rate of 82 bpm. These are normal observations.

11. A significant issue arises here because these BP readings conflict with an observation on the plaintiff’s Irish Maternity Early Warning System (“IMEWS”) chart, entered simultaneously by the midwife. IMEWS, is a nationally recognised tool for the early detection and treatment of life-threatening illness in the pregnancy and postnatal period. It sets out clinical signs and symptoms which if present prompt particular escalation measures. IMEWS records that the plaintiff’s BP was 76/38 at 02.00 (which is concerningly low), 96/48 at 02.10, and 101/52 by 02.20. It is common case that, under IMEWS, the first two BP readings would trigger immediate obstetric review. There is a dispute as to whether the failure to take this step represented sub-standard care.

12. At 02.40, the notes record a “total” PPH of 840 mls, which exceeds the sum of the previously estimated and measured blood loss events. In all likelihood, therefore this was because Nurse Wright had re-considered and increased her earlier estimation of blood loss. Indeed, both obstetric experts agree that 840 mls was probably still an underestimation of blood loss as of that time. Notwithstanding, the plaintiff’s vital signs, which were monitored every ten minutes, improved and as stated above, her BP gradually increased. By 03.00, BP was 126/74 (which is entirely normal).

13. At 03.15, the uterus was well contracted, and a “small gush” was noted. However, at 03.25, the uterus was soft on palpation (meaning that it was not contracting satisfactorily) and a further gush was noted. Dr. O’Higgins, Specialist Registrar in obstetrics, was called to review.

14. On review, at 03.30, Dr. O’Higgins noted that the delivery had experienced a PPH. Her impression was that the PPH was atonic in nature, meaning that it was attributable to poor uterine tone. Dr. O’Higgins’ clinical note records that the placenta and membranes had appeared complete and that a second-degree tear had been repaired. On examination, a small volume of clots was expelled from the uterus; the plaintiff was clinically well, and her vital signs were normal. However, the uterus was intermittently relaxing with associated vaginal blood loss (“PV loss”). Dr. O’Higgins directed second line prostaglandins to aid uterine contraction and tranexamic acid to promote blood clotting and prevent bleeding. She also requested anaesthetic review and a urinary catheter was placed. The plan was to replace IV fluids and monitor the plaintiff’s PV loss.

15. At 03.40 it was noted that the uterus remained atonic. Bleeding was well controlled by 04.10.

16. At 04.15, the plaintiff’s haemoglobin was reported at 10.3, which is indicative of only mild anaemia. Both obstetric experts agree that this a “false” reading, which did not reflect recent blood loss. Notably the plaintiff’s haemoglobin was 6.3 by the following day (which indicates blood loss of well over 1,000 mls).

17. At 05.30, the plaintiff was admitted to the post-natal ward. Her uterus was well contracted and clear urine was draining from the catheter.

18. In light of the plaintiff’s low blood count, a blood transfusion was recommended the following day. The plaintiff was initially reluctant to undergo blood transfusion, but she agreed to follow medical advice and was administered blood transfusions as required. Overall, post-natal maternal observations were reassuring. They variously record:

• Normal, average or minimal lochia with clear urine draining;

• that the uterus was well contracted and firm;

• that the plaintiff was postnatally stable, with “no concerns” and asymptomatic;

• that the IMEWS score was normal.

19. At 12.30 on 19.10.19 , the plaintiff was really keen for discharge but was encouraged to get breast feeding established and to get the baby’s weight checked the following day. The notes record that later that day the plaintiff was postnatally well and had decided to stay until the following day. At this stage, the baby was feeding well.

20. At 10.08 on 20.10.19, the plaintiff’s uterus was well contracted, and PV loss/lochia was average. The plaintiff was noted to be feeling well and to have no concerns. She was discharged at 10.15 on the same day and was advised to follow up with her GP as necessary.

21. On 04.11.19 the plaintiff was admitted by ambulance to the emergency department of the MRH, with a history of a heavy vaginal bleed and collapse at home. On arrival at the MRH, the plaintiff’s vital signs were normal. On speculum examination, blood loss was minimal. The plaintiff’s abdomen was soft and slightly tender and the uterus was not palpable. The plaintiff’s haemoglobin was 8.5 g/dl. The impression was of endometritis (infection of the lining of the womb). Vaginal swabs and bloods were taken for investigation. The plaintiff was admitted and commenced on antibiotics.

22. On 05.11.19, it was noted that bleeding had settled and that the plaintiff’s observations were stable. The plaintiff was reviewed by Dr. Maher, who works jointly between the Coombe and the MRH. An ultrasound of the uterus was reported as showing “clot… [and] endometrial thickening”. The plaintiff was treated with cytotec, a uterotonic agent, to promote uterine contractions and, if necessary, assist in the evacuation of the uterus. On 06.11.19 the plaintiff was discharged on oral antibiotics and iron, with a plan to rescan in two weeks.

23. On 11.11.19, the plaintiff attended her general practitioner noting that her blood loss had improved to spotting since her discharge from the MRH.

24. On 17.11.19 the plaintiff re-presented to the MRH with blood-stained vaginal discharge. The notes record that this “feels like it could be period”, and that the blood loss was not heavy and was odourless. Clinical examination was normal and the plaintiff was allowed home with instructions to return if concerned. The hospital agreed to “chase” the planned scan appointment as ordered on 06.11.19.

25. On 26.11.19 the plaintiff was referred by her general practitioner to the MRH emergency department due to further vaginal bleeding of a reported nineday duration. The plaintiff reported that she was soaking pads every three or four hours with clots and had seen some tissue. She was feeling weak and lethargic with crampy abdominal pain. The plaintiff’s haemoglobin was noted to be 11.3.

Transvaginal ultrasound showed clots in the uterine cavity measuring 3 x 3 x 4 cm. Although the plaintiff had been due to have a scan around 20.11.19, this had not occurred. The plaintiff’s observations were stable and she was referred to the gynaecological registrar. The diagnosis was of “retained POC” and the notes record that treatment was discussed as follows “discussed -conservative, surgical, medical”. The plaintiff was prescribed cytotec and scheduled for review in one week.

26. When seen on 04.12.19, for the planned one-week review, the plaintiff was still bleeding. Vaginal assessment revealed that the cervix was dilated and a 3 to

4 cm mass was palpable in the cervix. The differential diagnosis was of a pedunculated fibroid, polyp or RPOC. Ultrasound confirmed RPOC. The plaintiff was admitted for examination under anaesthetic (“EUA”) and probable ERCP.

27. ERPC was performed under general anaesthetic. The operative note records the removal of a specimen comprising, inter alia, RPOC.

THE ORAL EVIDENCE

28. Testimony was given in this case by the plaintiff and by her two expert witnesses, Dr. Robin Ashe, consultant obstetrician and urogynaecologist and Rachel Coleman, midwifery expert. The plaintiff also presented causation and quantum evidence from Prof. Jorgin Thakore, consultant psychiatrist. The defendants’ factual witnesses were Nurse Sylvia Wright of the Coombe and Drs. Amy O’Higgins and Niamh Maher of the Coombe and the MRH, respectively. The defendants called expert testimony from Dr. Peter Lenehan, consultant obstetrician and gynaecologist and Fiona Hanrahan, midwifery expert.

Plaintiff’s factual evidence

29. The plaintiff has several complaints against the Coombe. She contends that her labour was handled in a rough, unsympathetic manner, that her waters were broken without her consent, that she was denied an epidural and that there was an inadequate response to her PPH. The plaintiff also criticises the MRH for allegedly failing to diagnose RPOC, for failing to perform the planned follow up scan and for failing to perform ERCP at an earlier point in time. The following points of particular relevance arise from the plaintiff’s testimony:

30. She agrees that she first requested an epidural at 23.55. Once she was fully dilated, active pushing was extremely short, lasting only fifteen minutes or so.

31. The plaintiff states that her waters were broken without her consent, which although pain free, was shocking. She did not recall her consent being taken for either the ARM or the VE which accompanied it.

32. After her birth the plaintiff recalls several bleeds which she feels the midwife either failed to notice or tried to conceal. On the other hand, by the time she was brought down to the post-natal ward at 05.30, her bleeding was normal. The plaintiff agrees that on discharge from the Coombe she was told to come back in if she had any concerns.

33. The plaintiff states that after her discharge from the Coombe, she continued to experience severe bleeding which made her extremely tired. She was unable to carry or bathe Mia because she lacked the strength to hold her and was so weak that she was unable to leave the house.

34. However, the plaintiff’s evidence as to the blood loss experienced over this period was somewhat inconsistent. In her direct evidence, she described continuous bleeding accompanied by a lot of pain, which she knew was abnormal. However, she also stated that she understood the blood loss to be more or less as expected after childbirth, until she collapsed at home on 04.11.19. Certainly, she did not either contact her GP about the blood loss, or return to hospital in the period between 20.10.19 and 04.11.19.

35. The plaintiff’s blood loss and collapse at home on the 04.11.19, was distressing and frightening. The plaintiff has quite a limited memory of her inpatient treatment in the MRH but acknowledges that the doctors were careful to explain everything to her and to seek her consent to the course followed. Although she feels that she never fully understood why this heavy bleed had occurred, she understood that the medication prescribed was to assist her in expelling whatever was inside her uterus, which she understood was probably a clot or other small mass.

36. After discharge from the MRH on 06.11.19, the plaintiff continued to bleed intermittently. She stopped breastfeeding at three weeks due to blood loss and associated fatigue; she needed to be near a toilet and was still afraid to leave the house. By 17.11.19 she was still experiencing gushes of blood between two and four times a day and was concerned that this was abnormal. The plaintiff presented at the MRH and was apparently told that her bleeding was normal menstruation. The plaintiff recalls asking about the planned scan and that this was not offered.

37. The plaintiff states that she continued to experience two or three gushes of blood a day. She agreed however, that this blood loss was usually just like normal menstruation. The plaintiff was referred by her GP back to the ER on 26.11.19 where she states she was assured that this was normal bleeding and sent home. Under cross examination, she accepts that a transvaginal scan was performed. She also recalls it was explained that her cervix should be “smaller and more closed” and that she was given further uterotonics to try and naturally expel whatever was inside the uterus. In addition, a follow up appointment was also made for a week’s time on 04.12.19, pursuant to which an ERCP was performed.

38. The plaintiff’s evidence was that she remained weak, fatigued and introverted for some time after the ERCP. She did not return to normal for nearly two years and was commenced on antidepressants, which she continues to take. Fortunately, the plaintiff states that she is now doing really well; she has a good life and feels very happy.

Plaintiff’s expert evidence

Plaintiff’s obstetric evidence: Dr. Ashe

The Coombe management of labour and primary PPH

39. Dr. Ashe’s expert report makes the following criticisms of the plaintiff’s care in the Coombe. Management of the third stage of labour expectantly (rather than actively) fell below an accepted standard of practice. The attendants failed to recognise that the placenta was incomplete at delivery. Management of the PPH fell below an acceptable standard of practice. BP observations recorded at 02.00 are inconsistent and the IMWES entry indicated cardiovascular compromise which demanded a more urgent and clear response.

40. Dr. Ashe’s report makes the following criticisms of the plaintiff’s care in the MRH. Management of the secondary PPH between 05.11.19 and 06.11.19, fell below an accepted standard of practice. The ultrasonography undertaken on

05.11.19 lacks detail and context. Discharging the plaintiff for conservative (i.e. “wait and see”) management over the course of a further two weeks, and the failure to organise the planned two-week outpatient examination and ultrasound scan, were unacceptable. Thereafter protracted conservative management during the plaintiff’s ensuing presentations to the MRH between 17.11.19 and 04.12.19 was also inappropriate.

Expectant management of the third stage of labour

41. Established labour was noted at 23.55 and a normal delivery occurred at

01.03. Dr. Ashe defines this labour as a “precipitate labour”, which is a risk factor for primary PPH. In such circumstances, active management of the third stage is mandatory. Dr. Ashe notes that whilst the contemporaneous continuation notes record delivery by controlled cord traction, they do not record that syntocinon was administered and that active management cannot therefore be confirmed. Pursuing expectant rather than active management, fell below an expected standard of practice in the absence of the informed consent of the plaintiff to this course of management.

42. In cross examination, Dr. Ashe accepted that the summary of labour (a proforma filled out by the midwife in charge of the plaintiff’s labour) records that the third stage was managed actively and that syntocinon was administered intramuscularly, albeit that the timing of such administration is unclear. In addition, the typed midwifery report (which was filled out by the ward clerk on foot of the summary of labour proforma and signed in hand by Nurse Wright) also records that the third stage was actively managed by way of syntocinon. Further the typed GP discharge letter (also based on the summary of labour) records active management.

43. In response to this documentation, Dr. Ashe accepted that it would certainly be open to the court to conclude that the third stage was actively managed. Although he would have expected the continuation notes to expressly record active management of the third stage, Dr. Ashe effectively withdrew this criticism. He also confirmed that, if the third stage was actively managed, this would maximise the chances of a full and complete delivery of the placenta.

Lack of consent to ARM

44. Dr. Ashe stated that one would usually note consent for an ARM. However, if the midwife had explained to the plaintiff that she would undertake a VE and would perform an ARM at the same time if required, consent to the latter may not necessarily be recorded.

No epidural

45. Dr. Ashe did not criticise the fact that the requested epidural was not ultimately administered to the plaintiff. There are only so many anaesthetists in a busy maternity hospital. It is not unusual for a patient to request an epidural, but progress quickly to delivery before same is commenced.

“Placenta appears complete”

46. Dr. Ashe acknowledged that, although a midwife will have a highly trained eye from their years of experience, they cannot guarantee on visual examination that the placenta is complete, only that it “appears complete”. Aside from that, all that one can do is reduce the risk of RPOC as much as possible, by actively managing the third stage of labour.

Management of the PPH

47. While blood loss was estimated at 300 mls at delivery, estimated blood loss is inherently unreliable and this was almost certainly an under-estimation. Dr. Ashe stated that whilst it was therefore correct and indeed common practice, to administer additional syntocinon at 01.25, this nonetheless suggests that the midwife was somewhat worried about blood loss and that more urgent action ought to have been at least considered.

48. Dr. Ashe was highly critical of the discrepancy between the BP readings at

02.00. The IMEWS entry of 76/38 was so low as to suggest cardiovascular compromise. It also confirms that blood loss was significantly higher than estimated. As such, IMEWS recommends escalation as follows: “Call the obstetrician and request immediate review. Repeat a full set of observations within

15 minutes or monitor continuously”. Although the senior house officer, Dr. Chavez, was present at this time suturing the perineum, Dr. Ashe believes that Nurse Wright ought to have summoned an experienced obstetrician of at least middle grade, together with anaesthetic staff. In addition, the patient’s bladder should have been catheterised, as a full bladder can reduce contractability of the uterus, exacerbating uterine atony. Dr. Ashe was therefore somewhat critical of the delay in placing a catheter, which does not appear to have occurred until approximately 04.00.

49. Dr. Ashe was also critical of the fact that by 02.00 there had been two separate blood loss events totalling more than 500ml (first at 01.25 with estimated blood loss of 300 mls and secondly at 02.00 with blood loss measured at 340 mls).

In light of the plaintiff’s low BP, the 2016 RCOG Guidelines entitled “Prevention and management of PPH” (“the RCOG guidelines”) would classify the event as a major PPH, requiring an urgent response including blood transfusion if clinically required.

50. Crucially, however, notwithstanding these failings, Dr. Ashe concedes that bleeding was quickly controlled, and that the plaintiff’s BP quickly recovered. By

02.20 BP was normal, where it remained until 11.00 the following morning (when two readings demonstrate slightly low systolic BP, which subsequently normalised). Notwithstanding his criticism of the failure to call more senior obstetric and anaesthetic personnel between 02.00 and 03.25, Dr. Ashe accepted that the treatment administered was by and large reasonable. Thus, it was reasonable to respond by administering syntocinon and extra fluids and closely monitoring the plaintiff’s response by way of full observations every ten or fifteen minutes.

51. Dr. Ashe noted that, when she attended at 03.25, Dr. O’Higgins clearly considered RPOC in the differential diagnosis. He initially suggested that, given the plaintiff’s history, Dr. O’Higgins should have re-examined the placenta herself to check that it was complete. Ultimately, he accepted that this would not invariably be required. The patient was clinically well within a short period of Dr. O’Higgins’ attendance and the bleeding was controlled. This would all tend to shift one’s bias towards atony rather than RPOC. Dr. Ashe stated that Dr. O’Higgins “brought clarity” to the situation and he ultimately made no criticism of her management.

52. Dr. Ashe also accepted that all subsequent observations recorded average or moderate lochia and a well contracted uterus, which was reassuring.

53. Dr. Ashe’s oral evidence did not ultimately endorse the strong criticisms of the Coombe in his expert report. He effectively withdrew the criticism that labour had been managed expectantly rather than actively. He accepted that it is extremely difficult to confirm that a placenta is complete and that the standard notation “placenta appears complete” reflects this. This withdraws his criticism of the failure to recognise that the placenta was incomplete at delivery. Notwithstanding the fact that he continues to believe that more urgent action was required in response to the IMEWS BP recording at 02.00, Dr. Ashe acknowledged that the plaintiff responded to the treatment actually administered and that the situation had resolved itself by no later than 02.20. When asked, therefore, what turned on the failures of care identified above, Dr. Ashe’s response was that an hour was lost in diagnosing PPH and in summoning obstetric assistance. Dr. O’Higgins should have attended an hour earlier, which he states might have avoided the subsequent bleeds at 03.15 and 03.25. Certainly, any potential deficit in care was remedied when Dr. O’Higgins arrived at 03.30 and prescribed additional medication to combat uterine atony.

54. Overall, I think it is fair to say that Dr. Ashe’s criticisms of the management in the Coombe fell far short of an assertion that no reasonable obstetrician would act in a similar way if taking ordinary care.

The MRH management of secondary PPH

55. The key criticism of the MRH in Dr. Ashe’s report is that protracted conservative management, in the presence of repeated, often heavy bleeding and the failure of uterotonic agents, was sub-standard care. Whilst his report provides a number of examples of this sub-standard care, which I will detail below, Dr. Ashe softened and even retracted many of these points in his oral evidence.

Admission on 04.11.19

56. Dr. Ashe’s report maintains that the MRH was incorrect to diagnose endometritis rather than RPOC on the plaintiff’s admission to the MRH following her collapse at home on 04.11.19. However, under cross examination, Dr. Ashe accepted that endometritis is a known cause of secondary PPH and that the plaintiff’s elevated white blood cell count and CRP levels, together with tenderness of the lower abdomen is typical of an infected womb, which all supported that diagnosis.

57. Dr. Ashe’s report also suggests that the ultrasonography of 05.11.19 was inadequately performed or reported. In his oral evidence, Dr. Ashe accepted that there are well recognised difficulties in interpreting ultrasound scans so soon after delivery, which can make it very hard to distinguish between a clot and RPOC.

58. It was put to the Dr. Ashe that performing an ERPC on 04.11.19 would have been fraught with the catastrophic risk of uterine perforation. Dr. Ashe accepted that the risk of uterine perforation was greater at this time, two weeks postpartum, than at six weeks postpartum (when the ERCP was preformed). At two weeks post-partem the perforation rate of an ERPC could be as high as 1%. Many would consider six weeks postpartum the “safe border” in terms of the risk of uterine perforation. Nevertheless, Dr. Ashe remained of the view that obstetrics should be primarily preventative rather than reactive and that the controlled surgical risk of uterine perforation is to be preferred to the risk of uncontrolled bleeding in the community presented by conservative treatment.

59. Ultimately, however, Dr. Ashe accepted that whether to take the conservative route or to carry out an invasive clinical procedure is a clinical judgment call. Conservative management was not an unreasonable approach, as cytotec can lead to natural expulsion of both clots and RPOC, without the need for surgical intervention (unless the RPOC is adherent to the uterine wall).

60. Therefore, he accepted that Dr. Maher had correctly identified the differential diagnosis of infection and RPOC, made a clinical judgment as to how to deal with both potential diagnoses (antibiotics and uterotonics respectively) and had opted for the conservative route at two weeks postpartum which is not inherently unreasonable. Dr. Ashe’s remaining concern was that the notes did not clearly record a full discussion with the plaintiff as to the alternative management options and a record of her decision to opt for conservative management.

61. Separately, Dr. Ashe maintained that the decision, on discharge from the MRH on 06.11.19, not to schedule further assessment and re-scanning for a period of two weeks was “questionable”. However, nothing turns on this criticism because the plaintiff did not experience heavy bleeding (but rather “spotting” as her GP records) before spontaneously presenting to the MRH on 17.11.19 in any event.

62. Separately, Dr. Ashe criticised the MRH’s failure to carry out the scan that Dr. Maher had requested for two weeks time. However, the reality was that even if the repeat ultrasound had been carried out by the 19.11.19 or 20.11.19, it would not would necessarily have been diagnostic of RPOC as opposed to a clot. In any event, Dr. Ashe also confirmed that this issue falls away by the time of the differential diagnosis of RPOC on the 26.11.19.

Emergency Department on 17.11.19

63. Dr. Ashe was not particularly critical of the approach taken on 17.11.19, provided that it was discussed with the plaintiff, and she consented to the plan of management.

26.11.19

64. Dr. Ashe acknowledges that when the plaintiff presented on the 26.11.19, reporting heavy bleeding over the previous nine days, her normal haemoglobin levels did not suggest particularly heavy bleeding. Further, her CRP readings had come down, which is a positive sign that the suspected endometritis was responding to antibiotics.

65. In Dr. Ashe’s opinion the plaintiff’s pattern of bleeding was by then typical of RPOC and an ERPC was needed, with the patient’s consent. Instead it will be recalled that ultrasound assessment identified probable RPOC; that the clinical notes record that treatment options were discussed, in particular whether management should be conservative or surgical; that the decision was to manage the plaintiff conservatively by Cytotec; that an appointment was scheduled for one week’s time and that the plaintiff was told to come back in if she experienced heavy bleeding or pain.

66. Whilst Dr. Ashe initially stated that failure to perform an ERCP on 26.11.19 fell below the accepted level of practice, he ultimately accepted that if the conservative approach is discussed with and agreed by the patient, then it is within the band of acceptable management. In the closing few words of his direct examination, Dr. Ashe encapsulated his current position: “consultation relating to her options did not appear to be clear. That is what I think”.

67. Dr. Ashe acknowledged that the protracted period of conservative management ultimately turned out well from a gynaecological of view. The major downside of conservative management is of uncontrolled bleed at home, which did not come to pass. Furthermore, the prior period of conservative management made the ERCP on 05.12.19 more straightforward because the uterotonic agents had moved the RPOC to the neck of the womb. On the other hand, Dr. Ashe contends, not unreasonably, that this was a very anxious and difficult time for the plaintiff. She had difficulty feeding her baby, she was unable to go out of the house and developed mental health problems, all of which is highly regrettable.

Plaintiff’s midwifery evidence: Ms. Coleman The Coombe: management of labour and primary PPH ARM

68. If the court accepts the plaintiff’s version of events concerning the ARM, then Nurse Wright did not explain the process and rationale of the ARM. This, Ms. Coleman states, would amount to a failure to maintain the communication expected of a midwife of like specialisation and skill acting with ordinary care. On the other hand, Ms. Coleman acknowledges that such failure, if established, did not have any causative impact on the plaintiff’s PPH.

69. It was put to Ms. Coleman that the protocol in the Coombe was to perform a VE and ARM pre-epidural. Whilst she was surprised that a maternity hospital would follow such an interventionist approach unless specially requested by a patient, Ms. Coleman acknowledged that an ARM would enable one to check that the liquor is clear, as an indication of foetal well-being before proceeding to epidural. She was therefore not particularly critical of the Coombe protocol per se, provided consent is obtained.

Epidural

70. Although the plaintiff had made it clear that she would want one in due course, it was perfectly acceptable not to offer the epidural until labour was established. Ms. Coleman also accepted that whilst preparations were made for an epidural, which was good practice, the plaintiff’s labour progressed very fast and there was in reality no time for an epidural.

Expectant/Active Management of the third stage

71. The timing of the administration of intramuscular syntocinon ought to have been recorded on the contemporaneous continuation notes. However, given that the notes record both intramuscular syntocinon and controlled cord traction, Ms. Coleman concedes that in all likelihood intramuscular syntocinon was given at the time of delivery in accordance with the procedure for active management.

“Placenta appears complete”

72. Whilst an experienced midwife will generally know whether a placenta appears complete or incomplete and whether the membranes are ragged or otherwise, Ms. Coleman accepts that one could not guarantee that every single piece of the placenta has been delivered. If a midwife has a concern, they should pass it up the line to a more senior midwife or for a medical review.

01.25

73. When the plaintiff’s placenta was delivered, the midwife estimated blood loss of 300 mls and documented that some clots were present. According to the RCOG guidelines, PPH is only established when blood loss exceeds 500 mls, suggesting that no further intervention was required at this time.

74. On the other hand, it is more accurate to weigh than to estimate blood loss, particularly when clots are present. Ms. Coleman states, on the balance of probabilities, that if Nurse Wright had weighed the blood loss, escalation to a senior obstetrician would have occurred very shortly after 01.25.

75. Having said that, Ms. Coleman acknowledged that at the time of this delivery it was acceptable to simply estimate blood loss unless one was concerned that it was abnormal. She suggested that the additional does of syntocinon administered at 01.25 suggested that Nurse Wright had such a concern. I would be slow to draw this inference as administering additional syntocinon appears to be a reasonably routine step. I do note that, at 02.40, Nurse Wright retrospectively increased her estimate of the 01.25 blood loss (from 300 to 500 mls). I also accept that blood loss of this volume would, if appreciated at 01.25, trigger the PPH protocol. However, as it was acceptable to estimate (rather than weigh) blood loss at 01.25 and given that, even with proper care and skill this can underestimate volume, this retrospective increase could not give rise to legitimate criticism of the management at 01.25.

02.00

76. Although her report makes no criticism of the management at 02.00, Ms. Coleman’s oral testimony did. The plaintiff’s BP as recorded on the IMEWS chart, 76/38, was dangerously low. With every passing minute the plaintiff could lose up to 600 mls of blood. Ms. Coleman states that this is an emergency which requires escalation to an obstetrician and a full team to manage the PPH and work out where the bleeding was coming from.

77. Whilst Ms. Coleman acknowledged that the plaintiff appeared to recover quickly at 02:00, she said that the primary question was whether the two subsequent bleeds could have been avoided had an obstetrician been called at

02.00. This clearly turns on what an obstetrician would have done had they been called at 02:00.

78. In her oral evidence Ms. Coleman stated that all that the team really did at

02.00 was fill the plaintiff up with two litres of fluid to maintain BP. This is incorrect. For example, a syntocinon infusion was commenced and full bloods were sent to the laboratory. Within a very short period, the plaintiff’s uterus was noted as well contracted, the plaintiff was recorded as asymptomatic, and Dr. Chavez documented that haemostasis was achieved. According to Ms. Coleman’s report this all meets the standard of care.

Gush at 03.15 and 03.25

79. Although a small gush is recorded at 03.15, the plaintiff’s uterus was recorded as well contracted, which is re-assuring. On the other hand, Ms. Coleman also stated that even though the notes suggested that the subsequent two gushes were smaller, a “gush” could still be 100 mls. This is still of concern and therefore should have been measured.

80. Save that it should also have been measured, Ms. Coleman makes no substantial criticism of the response to the gush noted at 03.25. The midwife duly noted that the uterus was soft on palpation, recognised that this indicated PPH, and escalated the matter to Dr. O’Higgins.

Post Natal Ward

81. Ms. Coleman notes that prior to the transfer to the postnatal ward the plaintiff’s bleeding was “now controlled”, her lochia was “average” and that her “obs [were] stable, bleeding now settled.” She states that the plaintiff’s condition at this time would not have raised any concerns. Midwifery care during this period was of an expected standard.

82. Ms. Coleman also accepted that after the plaintiff was transferred to the post-natal ward her observations remained reassuring and so postnatal care was generally of the expected standard.

83. However, she is justly critical of the fact that twelve hours passed without observations between 05.30 on 17.10.19 and 18.00 on 17.10.19. Having suffered a PPH, the plaintiff should have been on four hourly observations at a minimum. However, this did not impact the plaintiff’s well-being as, when observations were taken at 18.00 on 17.10.19, they were stable

84. Ms. Coleman also notes that the plaintiff’s lochia was documented as “moderate” at 23.30 on 17.10.19. She interprets this as a change from the previous documentation of “average” lochia and criticises the midwife for failing to undertake a uterine palpation, take a full set of maternal observations and inform a doctor. Ms. Hanrahan, the defendant’s midwifery expert, makes a similar criticism in this regard. Again, however, nothing turns on this omission as the plaintiff’s observations after this were all reassuring.

85. Ms. Coleman makes the same complaint vis-a-vis the midwifery examination at 08.40 on 18.10.19, particularly as by that stage the plaintiff’s haemoglobin level was reported at 6.5, down from 10.3 the night before. Ms. Hanrahan, the defendant’s midwifery expert, makes a similar criticism in this regard. However, both midwives agree that if palpated, the uterus would, on the balance of probabilities, have been well contracted.

Plaintiff’s pyschiatric evidence: Prof. Thakore

86. Prof. Thakore, consultant psychiatrist, outlined the history given to him by the plaintiff. Thus, the plaintiff told him that after she had her second baby, she lost a lot of blood and was very weak. She informed him that she knew something was wrong because the bleeding and tiredness was much more than she experienced after having her first child. She went to her GP and the MRH several times following the birth and, even though she was bleeding massively, she was told that everything was normal. The plaintiff was told that she had retained part of her placenta and that her uterus was therefore not contracting. She was given three to four rounds of medication to help with this, but eventually required surgery in the MRH.

87. In Prof. Thakore’s opinion, the plaintiff was not suffering from a formal mental disorder at the time of this review on 29.10.24. However, in his opinion the plaintiff would have fulfilled the DSM-V criteria for an adjustment disorder for approximately two years after the birth of her second child.

88. When asked to identify the stressor giving rise to the plaintiff’s adjustment disorder, Prof. Thakore identified the fact that the plaintiff had to go back into the MRH and undergo an ERCP under general anaesthetic. This, however, is something that would have been virtually unavoidable in any event.

Defendant’s factual evidence Nurse Wright

89. Nurse Wright had no recollection of the night in question. By the time of these events, she had worked in the Coombe, mainly in the labour ward for three years. On an average night, there could be 20 births in the Coombe. The ward was managed by a clinical nurse manager (“CNM”), who circulated around the corridor, allocated staff to different patients, oversaw management and assisted as required.

90. The protocol in the Coombe is that if a patient requests an epidural, it is necessary to perform a VE and ARM. Nurse Wright’s normal routine is to explain to a patient that she will need to perform a VE and an ARM at the same time, which she states would generally feel like a nail cut. If the patient agrees, she would then go ahead. Nurse Wright agreed that consent to an ARM cannot be assumed merely because one has consented to a VE. Nurse Wright is certain that she would have sought the plaintiff’s consent to an ARM. This is absolutely standard practice in every delivery in which an epidural is requested; it was, she stated, “like eating with a knife and fork”. Nurse Wright stated that she recorded “VE with consent” to reflect that she had explained all of the above. She stated that occasionally patients are under stress and do not recall everything that is discussed with them.

91. The Coombe protocol is to actively manage the third stage of labour unless otherwise requested by the patient. Nurse Wright’s usual practice is to record that active management has been followed in the continuation notes. She did not make this notation on this occasion, which she stated was due to human error. Nurse Wright is however absolutely confident that syntocinon was given before controlled cord traction because this is the default position; it is routine in virtually every single delivery. Nurse Wright confirms that she signed off on the note in the labour summary that active management was followed. Indeed, this document bears her signature.

92. Nurse Wright is experienced in placental examination. This would usually take five to ten minutes.

93. Whilst there would always be separation bleeding at the time of delivery in the form of brisk loss of small amounts of blood, clots were unusual which is why she specifically recorded same. Although Coombe policy requires that it is signed off by a CNM, it was reasonably routine to administer syntocinon after birth to control bleeding. Indeed, this potential step appears on the pro-forma. Nurse Wright was not concerned that there could be RPOC at 01.25, because often the uterus takes some time to clamp down.

94. This remained the position when the plaintiff bled a second time at 02.00. The plaintiff’s vital signs were essentially normal at that time on both readings on the continuation notes. When asked why she had not called for an obstetrician to review the plaintiff when required by IMEWS, Nurse Wright replied that this in all likelihood this was because the bleeding, which at that stage was thought to be under 500 mls, had stopped and there had been a very quick recovery. The plan, therefore, was to observe the plaintiff closely and if necessary, call the registrar. She further confirmed that she would in any event have escalated the matter to a CNM with whom she works as part of a team.

95. Nurse Wright stated that at 02.40, she evidently re-estimated the 01.25 blood loss from 300 to 500 mls. This is not unusual. It might have been a response to a discussion with a colleague present at the time of the delivery or with a CNM. Equally, it is possible that she did so spontaneously because bleeding had continued, which caused her to reconsider her earlier estimate. Nurse Wright states that notwithstanding her re-estimation of blood loss up to 840mls, she felt that the total PPH did not exceed 1000mls and was therefore not extremely serious. Both obstetric experts agree that this latter assumption was probably incorrect.

Dr. O’Higgins

96. At the time of these events, Dr. O’Higgins was an experienced specialist registrar in obstetrics. She has since qualified as a consultant obstetrician.

97. In the Coombe, where there are 6000 deliveries per annum, one would see at least one PPH each night, perhaps more.

98. When Dr. O’Higgins reviewed the plaintiff at 03.35, she was concerned that the uterus remained soft on palpation despite treatment. This was a clinical picture of atony, which is the primary cause of primary PPH. An atonic uterus will usually respond to medical management. Furthermore, if there is an element of RPOC, uterine atonics may assist in expelling this tissue.

99. Dr. O’Higgins stated that having examined and treated the plaintiff, she would not have left the room unless the uterus had adequate tone and the plaintiff’s clinical signs and vital signs were normal.

100. Whilst Dr. O’Higgins did not personally re-examine the placenta she stated that that is the nature of team responsibility. When asked in cross examination whether an obstetrician ought to have been called at 02.00 when the IMEWS readings so indicated, Dr. O’Higgins’ response was that there was an obstetrician in the room at this time, Dr. Chavez. This is a dynamic, evolving situation. The plaintiff presented with a transient drop in BP which can and did recover in a matter of minutes. If a cause for clinical concern had remained, then it would have been appropriate to escalate matters. Such decisions are taken in the overall clinical context, rather than on the basis of a tick box exercise such as is set out in the IMEWS.

Dr. Maher

101. Dr. Maher qualified as a consultant in 2016 and worked jointly between the Coombe and the MRH. Her only involvement with the plaintiff was over the course of the latter’s two-day admission to the MRH between 04.11.19 and 06.11.19 following her collapse at home.

102. When the plaintiff presented in the MRH, the likely diagnosis was either endometritis or clot/RPOC. Dr. Maher viewed each of these as equally likely. The plan of management was to address both aspects of this differential diagnosis. If the bleeding was caused by endometritis, then antibiotics would treat that within five to seven days. If, it was caused by clot or RPOC, then uterotonics would help to expel this matter from the uterus. Because the plaintiff was stable, it was not necessary to proceed to more active management by way of ERPC. Dr. Maher was further reassured by the fact that the plaintiff’s haemoglobin level had risen from

6.5 on discharge from the Coombe to 8.5.

103. Dr. Maher stated that in all likelihood she would have explained this differential diagnosis to the plaintiff. She would have explained to the plaintiff that if this were a case of RPOC, then ERPC might be required in the future. However, in giving this explanation, one would strongly advise the plaintiff against an ERPC at that stage because of the inherent risk of perforation so close to delivery.

104. Dr. Maher was emphatic that, due to the risk of uterine perforation, ERPC was not warranted at two weeks post-partum. Uterine perforation would be a catastrophic result for the plaintiff resulting in uncontrolled bleeding, hysterectomy or worse. It was not clinically necessary to expose the plaintiff to that risk, particularly in light of the stability in her clinical findings. Although therefore clots/RPOC were within Dr. Maher’s differential diagnosis, her clinical judgment was that the appropriate course of action was to manage the plaintiff conservatively.

105. Dr. Maher confirmed that she had intended that the plaintiff would be rescanned after two weeks to see if the infection had resolved and/or if the clots or RPOC had expelled. She would have also emphasised to the plaintiff that if she had a bleed in the community, or if she had any other concerns, she should come back. Dr. Maher’s own view was that this was unlikely to occur and that after a period of observation to let her home.

Defendant’s expert evidence

Defendant’s obstetric evidence: Dr. Lenehan

The Coombe

106. Dr. Lenehan believes that, at all times, it was reasonable for the Coombe to make a working diagnosis of an atonic uterus (the most common cause of primary PPH).

107. The totality of the notes leaves no doubt that the third stage of labour was actively managed, which is the absolute default position in Irish maternity hospitals. The third stage of labour was therefore managed in accordance with acceptable practice.

108. In Dr. Lenehan’s view, 10% of labours will be associated with overall blood loss of 500 mls or greater. One would usually expect between 200 and 250 mls blood loss at the time of the delivery of the placenta. Whilst 300 ml is slightly larger than expected, it was not particularly abnormal. Although clots are not in and of themselves alarming, from a clinical perspective they make it harder to estimate blood loss.

109. The midwifery response to this estimated blood loss of 300 mls at 01.25, which was to put up a drip administering syntocinon and await developments was perfectly appropriate. In Dr. Lenehan’s experience it would be part of good team practice to inform one’s CNM and obtain sign off for the syntocinon drip, as occurred here. Dr. Lenehan is not critical of the fact that no doctor was involved at 01.25. This was not necessary as blood loss was estimated at less than 500 mls. He emphasised that in Irish Maternity Hospitals, midwives and clinicians work together as a team. Midwives generally run the labour ward with a great deal of autonomy, escalating to medical practitioners where necessary.

110. Dr. Lenehan noted that, when a further 340 mls of blood loss was noted at 02.00, the plaintiff’s presentation was passing into the realm of PPH. The RCOG Guidelines, which were followed by most obstetricians in Ireland at the time of the plaintiff’s delivery, recommend that in the case of minor PPH, (which is defined as PPH of between 500 mls and one litre without clinical shock), first line medical and anaesthetic staff should be involved, which did not occur in this case.

111. Despite the fact that this was not actioned, Dr. Lenehan believes that management was entirely appropriate. The incompatibility between the IMEWS BP and the two normal BP recordings taken by the midwife at the same time, suggests to Dr. Lenehan that the IMEWS reading could be an error, perhaps as a result of an improperly applied cuff. It could also be a simple outlier, signifying nothing more than a vasovagal episode (which can occur when a clot passes through the cervix). Thus, one’s first reaction to low BP such as that noted here would be to take the BP again. Whilst the precise sequence of events as between the notation on the IMEWS and the two normal notations on the continuation notes is unclear, the critical point is that any abnormality corrected itself very quickly. The IMEWS reading at 02.10 shows recovery, albeit not complete recovery. With a significant PPH one would not expect such a quick recovery. Increasing uterotonic agents was therefore a reasonable and effective response. Furthermore, Dr. Chavez was in the room at that stage and medical aid was therefore available if needed. Although Dr. Chavez was there to repair the vaginal tear, she was working in a team environment and would have been fully aware of the context. The plaintiff’s observations returned to normal within 20 minutes, validating the team’s management strategy.

112. In Dr. Lenehan’s view, it is reasonably common to re-estimate blood loss. He was therefore not critical of, or surprised by, the upwards estimation of blood loss at 02.40, which whilst greater than previously, was still thought to be within the minor PPH range. However, Dr. Lenehan conceded that it is also quite possible, in light of the plaintiff’s very low blood pressure, that by then this was a case of major PPH requiring the involvement of more senior team members.

113. Notwithstanding this, even if the full extent of the blood loss had been recognised at either 02.00 or 02.40, this would not have changed management. Even if Dr. O’Higgins had been called at 02.00 or at 02.40, it is likely that she would have proceeded precisely as the midwives did, save that she may have catheterised the plaintiff. As such the further bleeds at 03.15 and 03.25 could not have been prevented by the attendance of medical staff or anaesthetic staff at

01.25 or 02.00.

114. Dr. Lenehan fully rejected the suggestion that either an EUA or an ERPC ought to have been performed in the Coombe. In light of the risk of uterine perforation, this would be an unacceptably high-risk approach. In addition, there would be very little to be gained from scanning the plaintiff before discharge from the Coombe. A scan within days after delivery will simply reveal blood and debris in the uterus, which would not in any way assist with management.

The MRH

115. The plaintiff presented to the MRH following a blood loss and a collapse at home. The ambulance service recorded that the plaintiff was not bleeding at the time of their first intervention. Her observations and vital signs both in the ambulance and in the MRH were stable. Although the plaintiff was recorded to be pale, weak and tired, this is to be expected after a bleed. Although the plaintiff estimated that she had lost 500 mls of blood, this is unlikely as one would expect her haemoglobin to be 6 or less in such circumstances.

116. A clinical diagnosis of endometritis was made, and the plaintiff was treated with antibiotics and monitored. Ultrasound the following day was reported as showing a clot in the uterus. Dr. Lenehan states that a clot can appear very similar to RPOC and makes no criticism of the interpretation of the ultrasound. In any event, it was clearly in Dr. Maher’s mind that this could be RPOC.

117. Dr. Lenehan was fully supportive of the opinion not to proceed to ERCP at this stage. Surgical intervention would be “wrong” because the risks of uterine perforation two or three weeks after delivery are very significant, particularly in the presence of a potentially infected uterus. Usually, the risk of such uterine perforation would be 1%, but in the circumstances presenting, this risk would be increased five-fold to 5% i.e. 1 in 20. Perforation of the uterus is a life-threatening condition which can lead to sepsis and hysterectomy. One would only intervene surgically at this stage if one had no other choice.

118. The plaintiff was kept in the MRH for a further two days, during which her vital signs were normal, and no significant bleeding was noted. Dr. Lenehan stated that one would have expected a discussion with the plaintiff prior to her discharge from the MRH on 06.11.19 as regards the plan of management. The strong bias of such discussions would be towards conservative management. Dr. Lenehan states that one would not necessarily expect this discussion to be noted.

119. Dr. Lenehan noted that although it was intended that the plaintiff would have a scan in two weeks this was not in fact organised. However, she spontaneously presented on 17.11.19 with a small PV bleed. The plaintiff felt “well” and had an IMEWS score of zero. It was appropriate at this stage to examine the plaintiff and advise her to come back if she was not improving.

120. The plaintiff presented to the MRH on 26.11.19, with nine days of bleeding recorded. The plaintiff’s clinical signs and symptoms indicated a satisfactory response to antibiotics; this tipped the diagnosis towards RPOC. Different management pathways, conservative, medical and surgical, were considered and discussed with the plaintiff. It was reasonable to treat her conservatively with uterotonics in the hope that the material in the uterus would pass. She was scheduled for follow up in eight days.

121. By the time of follow up appointment on 04.12.19, the plaintiff was still bleeding but the scan showed persistent abnormality. By this time, the uterine infection had been cleared by antibiotics, creating a sterile operative field. At six weeks post-partum, the risk of uterine perforation is reduced. It was therefore entirely appropriate to proceed to evacuation.

122. Dr. Lenehan noted that the ERPC operative note recorded that the RPOC had moved from the uterus to the cervix with the aid of the uterotonics. The plaintiff had therefore nearly passed the RPOC by the time she presented on

04.12.19 and was somewhat unlucky to even require an evacuation. The histology report following the ERCP notes that the pieces removed on 04.12.19, measured

3.5 x 3.9 cms in total, and were a combination of chorionic villi (part of the placenta) , decidua (part of the lining of the uterus) and organised blood clot. The RPOC were therefore, only a small component of what was ultimately removed.

Defendant’s Midwifery evidence: Ms. Hanrahan

123. With some minor exceptions, Ms. Hanrahan’s opinion is that the midwifery care for labour, delivery and post-partum was appropriate. To reduce repetition, I will detail only those aspects of Ms. Hanrahan’s evidence which have not already been the subject of analysis in the context of the other expert evidence.

124. Under cross-examination, Ms. Hanrahan confirmed that the plaintiff should be informed and should understand that an ARM is going to be performed. She fully acknowledged that, if the plaintiff did not know that an ARM was going to be performed, this would be unacceptable.

125. Ms. Hanrahan confirms that it is entirely standard before an epidural to rupture the membranes, but accepts that the documentation should have recorded the rationale and consent for the ARM.

126. Although PPH is defined as blood loss of over 500 mls one is primarily concerned with blood loss of over a litre. In Ms. Hanrahan’s experience, blood loss of up to a litre would occur in up to 25% of births. On the evening in question, the Coombe could have had two or three other PPHs of this magnitude. Ms. Hanrahan confirmed the inaccuracy of estimated blood loss and stated that, whilst at that time it was standard to estimate blood loss if one is not particularly concerned about same, it is now standard practice to measure all blood loss.

127. Once the initial PPH was observed at 01.25, Nurse Wright would have spoken with the CNM to agree a course of action, in this instance a syntocinon drip. Usually, the CNM’s involvement would have been recorded with a notation along the line “CNM aware” or “CNM informed and approved”. Notwithstanding this, Ms. Hanrahan stated that the CNM’s “fingerprints [were] all over” this aspect of care, as syntocinon could not otherwise have been administered. There was no need to call a registrar at 01.25. The CNM was aware of developments and the PPH was thought to be very minor and responded to prophylactic syntocinon. In any event, on a busy labour ward such as the Coombe, the registrar would have been just outside the door if their presence was needed.

128. The PPH at 02.00 was recognised, and appropriate first line drugs were administered. The clinical response taken to the further bleed and any drop in BP, was appropriate and effective. It was therefore acceptable not to escalate matters to a registrar. This is a common situation in a busy labour ward. Management of the situation presenting was within the remit of a senior midwife and her CNM, albeit that catheterisation ought to have occurred at this point.

129. The uterus was noted to be soft with a further gush of blood at 03.25 and the registrar was appropriately called and attended at 03.30. This was acceptable care.

130. Ms. Hanrahan was somewhat critical of the absence of a Coombe proforma for management of PPH at this time. A proforma is useful in defining roles and timings of actions during this obstetric emergency. On the whole, however, from a midwifery perspective, she believes that the PPH was appropriately managed.

131. Ms. Hanrahan agreed with Ms. Coleman’s minor criticisms of post-natal care. Despite this, postnatal care was appropriate. With the exception of one notation of moderate PV loss, the plaintiff’s lochia was average, her maternal observations were normal and stable, the uterus was noted to be well contracted and the plaintiff was generally well.

LEGAL PRINCIPLES RELATING TO THE STANDARD OF CARE

132. The standard of care is to be determined on the basis of the principles (the “Dunne principles”) established in Dunne v. National Maternity Hospital [1989] IR

91 (“Dunne”) (per Finlay C.J., p.109):

1. The true test for establishing negligence in diagnosis or treatment on the part of a medical practitioner is whether he has been proved to be guilty of such failure as no medical practitioner of equal specialist or general status and skill would be guilty of if acting with ordinary care.

2. If the allegation of negligence against a medical practitioner is based on proof that he deviated from a general and approved practice, that will not establish negligence unless it is also proved that the course he did take was one which no medical practitioner of like specialisation and skill would have followed had he been taking the ordinary care required from a person of his qualifications.

3. If a medical practitioner charged with negligence defends his conduct by establishing that he followed a practice which was general, and which was approved of by his colleagues of similar specialisation and skill, he cannot escape liability if in reply the plaintiff establishes that such practice has inherent defects which ought to be obvious to any person giving the matter due consideration.

4. An honest difference of opinion between doctors as to which is the better of two ways of treating a patient does not provide any ground for leaving a question to the jury as to whether a person who has followed one course rather than the other has been negligent.

5. It is not for a jury (or for a judge) to decide which of two alternative courses of treatment is in their (or his) opinion preferable, but their (or his)

function is merely to decide whether the course of treatment followed, on the evidence, complied with the careful conduct of a medical practitioner of like specialisation and skill to that professed by the defendant.

6. If there is an issue of fact, the determination of which is necessary for the decision as to whether a particular medical practice is or is not general and approved within the meaning of these principles, that issue must in a trial held with a jury be left to the determination of the jury.

133. In Morrissey v. HSE [2020] IESC 6, Clarke C.J. observed that the test in Dunne remains the basis for identifying the legal standard of care by reference to which a claim in clinical negligence is to be assessed and stated:

In my view, the various aspects of the Dunne test identified by Finlay C.J.

can be reduced to one overarching principle with a number of subsidiary considerations which impact on the application of that overarching principle in particular circumstances. The overarching principle is to be found in point (1); the standard of approach of a medical professional is to apply a standard appropriate to a person of equal specialist or general status acting with ordinary care. A failure to act in that way will amount to negligence.

134. Clarke C.J. summarised the legal standard of care in a clinical negligence claim: “ In substance, the legal standard of care applied in any clinical negligence claims, or indeed other professional negligence claims, requires the court to assess whether no reasonable professional of the type concerned could have carried out their task in the manner which occurred in the case in question. That overall test requires a court to determine what standard a reasonable professional would apply.”

135. In accordance, with Morrissey, the court must determine: “what would an ordinary competent professional of the type and skill of the individual concerned have done, and did the professional who is sued meet that standard?”

136. This is a two-stage process.

137. First, the court must identify “what would an ordinary competent professional of the type and skill of the individual concerned have done”. This is known as the standard of approach. The correct standard of approach is one of fact in each case. It is not for the court to determine the standard of approach or impose its own views as to the requisite standard of approach. Rather, it is the standards of the profession itself as demonstrated, by the evidence, that impose the standard required. Expert evidence is required as to how professionals of the relevant type would generally go about their work and the way in which they would have dealt with the case in question. In this case, the court must apply to the Coombe and the MRH, the standard of approach of experienced midwifery and obstetric/gynaecological clinicians working in a busy maternity teaching hospital and in a general hospital respectively.

138. Having established the correct standard of approach, the second stage of the process requires the court to consider whether the Coombe and the MRH complied with that standard in each respect.

139. Both parties in the present case accept that the Dunne principles apply to both the diagnosis, or otherwise, of RPOC and to the treatment options for PPH or RPOC as the case may be. This case turns primarily on the first Dunne principle: the question is whether the plaintiff has proved the clinicians in SJH have been “guilty of such failure as no medical practitioner of equal specialist or general status and skill would be guilty of if acting with ordinary care.”

140. However, the fourth and fifth Dunne principles are also of relevance in this case. Commenting on points (4) and (5) as identified by Finlay C.J. In Morrissey Clarke C. J. noted at para 6.10 that "[where] there are two or more schools of thought as to what course of action should be adopted in particular circumstances, it is clearly the case that a professional exercising reasonable care may adopt one of them even though there may be others who would take a different course."

APPLICATION OF LEGAL PRINCIPLES

The Coombe: management of labour and primary PPH

Consent to ARM

Standard of approach

141. When a patient requests an epidural, it is routine practice in the Coombe (and, as I understand it, in other Irish maternity hospital) to first perform an ARM to confirm foetal wellbeing. Although the plaintiff’s experts would have adopted a less interventionist approach, I am satisfied that there are “two or more schools of thought as to what course of action should be adopted” in the event of a request for epidural. The standard of approach clearly encompasses both. Indeed, I do not understand the plaintiff’s expert to contend to the contrary.

142. It is common case that the standard of approach requires that a patient’s consent to ARM must be obtained before this procedure is performed. Even if a patient has given their informed consent to a VE, this cannot be interpreted as a consent to ARM, unless specifically sought and obtained. If consent to ARM is given, then it would be usual to record same on the continuation notes.

Did the Coombe comply with the standard of approach as regards consent to ARM?

143. Nurse Wright has no specific memory of treating the plaintiff, her testimony relied upon her routine practice. There is nothing surprising about this.

144. Nurse Wright’s routine practice would be to simultaneously seek consent to both the VE and the ARM. The chart records the plaintiff’s consent to the VE and Nurse Wright is satisfied that this means that consent to both procedures was simultaneously sought and obtained.

145. The plaintiff was adamant that her consent to ARM was not sought. She also has no recollection of consenting to the VE even though this is expressly recorded on the continuation notes. This suggests that the plaintiff’s memory of these events may be imperfect.

146. I accept Nurse Wright’s evidence on this issue. Whilst the plaintiff’s consent to ARM ought to have been recorded on the chart, this omission is not sufficient to establish that Nurse Wright did not comply with her routine practice of simultaneously seeking consent to both a VE and an ARM. I am satisfied that, if the plaintiff had declined her consent to ARM, Nurse Wright would not have proceeded to break her waters. I am also satisfied that, if such consent had been declined, this would have been noted on the chart. Indeed, in light of the plaintiff’s request for an epidural, it is likely that the care could have been escalated in such circumstances.

147. The labour ward is a stressful environment for patients, and it may well be that the plaintiff did not fully take in what Nurse Wright explained to her in advance of the ARM. She may not have absorbed the nature of the procedure to which her consent was sought. Whilst this is unfortunate, it does not in itself give rise to a cause of action. I also note that the plaintiff did not inform Prof. Thakore that an ARM had been performed without her consent. Therefore, even if the plaintiff did not fully understand this aspect of the consenting process, it does not appear to have contributed to her adjustment disorder or to have caused her any injury.

Request for epidural

Standard of approach

148. The standard of approach in relation to epidurals was not expressly addressed by the experts. I assume that, once the patient is in established labour, it is standard of approach in Irish maternity hospitals to administer an epidural, provided same is not contraindicated and there is sufficient time to do so.

Did the Coombe comply with the standard of approach as regards the request for epidural?

149. It is common case that the epidural requested by that plaintiff when labour was established was not administered prior to delivery. It is evident that whilst preparations were being made for an epidural, which is good practice, the plaintiff delivered before an epidural could be administered. The plaintiff’s experts made no criticism of this, and no breach of care arises.

Expectant/active management of the third stage

Standard of approach.

150. I am satisfied that, unless otherwise requested by the patient, it is standard of approach to actively manage the third stage of labour. I am also satisfied that this reduces the likelihood of PPH.

Did the Coombe comply with the standard of approach as regards active management of the third stage

151. In initially contending that the plaintiff’s third stage was not actively managed, Dr. Ashe had overlooked several references to active management in the clinical chart. Whilst active management ought to have been expressly noted in the continuation notes, same is referred to in the labour summary, the pro forma chart and the GP discharge letter. When these were entries were drawn to his attention, Dr. Ashe conceded that the chart as a whole was certainly open to the interpretation that active management had been followed. Nurse Coleman agreed.

152. I am entirely satisfied that the active management approach was followed in this case.

Failure to recognise that the placenta was incomplete at delivery

Standard of approach

153. The unanimous testimony of the obstetric and midwifery experts is that the standard midwifery notation following the placental examination, namely, “placenta appears complete” or “placenta appears incomplete” impliedly acknowledges the fact that such examinations cannot guarantee that every single piece of the placenta has been delivered.

Did the Coombe comply with the standard of approach as regards the examination of the placenta?

154. I am satisfied that Nurse Wright is a very experienced midwife who examined the placenta in a standard manner.

155. I accept Dr. Lenehan’s view that the histology report shows that only a small piece of the placenta was retained. There is no credible suggestion that the mass of retained products in this case was such that Nurse Wright’s impression that the placenta appeared complete represented substandard care.

156. Dr. Ashe initially suggested that, when Dr. O’Higgins was called at 03.25 following the plaintiff’s primary PPH, it was incumbent upon her to go to the sluice room and reexamine the placenta herself. However, he later acknowledged that whilst this might be his own personal practice it was not invariably required. Specifically, he did not suggest that Dr. O’Higgins’ failure to do so constituted substandard care.

Blood loss events

Standard of approach

157. Diagnosis of primary PPH requires 500 mls of blood loss within a 24-hour period following delivery. A PPH of between 500 and 1000 mls is classified as a minor PPH. If a PPH is over 1000 mls, or if there is evidence of cardiovascular compromise, then it would be classified as a major PPH.

158. I am satisfied that the standard approach at the time of the plaintiff’s delivery was that blood loss was generally estimated rather than weighed, save in cases of particular concern. I am also satisfied that the estimation of blood loss is inaccurate. In particular, the presence of clots may lead to an underestimation of volume.

159. I note that the various guidelines referred to by the experts in this case advocate for slightly different responses to PPH.

160. The IMEWS system advises that, in the presence of certain triggers, such as very low BP (which is recorded in the present case), the midwife in charge should call an obstetrician, request immediate review and thereafter either repeat a full set of observations within 15 minutes or monitor the patient continuously. Having said that, the IMEWS system also recognises the importance of clinical judgment. It states that one must consider the context, complete a full clinical assessment and implement measures to reduce triggers “if appropriate.”

161. The RCOG Guidelines recommend that in the case of a minor PPH the midwife in charge alerts first line obstetric and anesthetic staff. In the case of a major PPH together with ongoing bleeding or clinical shock, a multidisciplinary team involving senior members of staff should be summoned to attend. Treatment measures for a minor PPH include intravenous access, urgent venepuncture (for full blood count and coagulation screen), observations every 15 minutes and commencement of a crystalloid infusion to restore circulatory volume. In the case of a major PPH with continuing bleeding or clinical shock, escalated measures are advised such as blood transfusion if clinically required, further fluid resuscitation and pharmacological mechanical and surgical methods to arrest PPH. If these methods fail to arrest the hemorrhage, then surgical intervention should be initiated sooner rather than later.

162. The 2017 Guidelines on Intrapartum Care for Healthy Women and Babies prepared by the National Institute for Clinical Excellence (“the NICE Guidelines”), which Ms. Coleman states comprises the standard of approach for midwifery care, advise slightly different measures such as calling for help, emptying the bladder, uterine massage, uterotonic drugs, intravenous fluids and supplementary oxygen.

163. What is clear from the above is that different guidelines recommend slightly different responses and treatment measures on diagnosis of either minor or major PPH. What they have in common is the summoning of qualified members of staff, close observation of the patient and taking all necessary and appropriate measures to stop bleeding and to resuscitate and stabilise the patient.

164. I am satisfied that the precise sequence of steps outlined in the IMEWS, RCOG and NICE Guidelines, are guidelines and not a mandatory set of tick box steps. One does not manage a patient by rote, but by applying clinical judgment and experience to their symptoms and clinical signs.

165. I am therefore satisfied that although guidelines may direct a particular sequence of management, the standard of approach permits midwifery or obstetric staff in a given case to select the care pathway that is appropriate to the clinical circumstance. Specially, I am satisfied that if a patient recovers quickly without requiring all of the potential interventions advised in the IMEWS, RCOG or NICE Guidelines, then further escalation is neither required, not desirable.

Did the Coombe comply with the standard of approach in its response to the plaintiff’s blood loss events?

Blood loss event at 01.25

166. Nurse Wright estimated blood loss at delivery of the placenta at 300 mls. On the balance of probabilities, blood loss was somewhat higher than estimated. Indeed, Nurse Wright evidently came to this view and, at 02.40, increased her overall estimate of blood loss to reflect this.

167. I therefore find on the balance of probabilities that the plaintiff’s actual blood loss at 01.25 probably comprised a minor PPH. However, it is common case that it was within the standard of approach at the time of this delivery to visually estimate blood loss, even though same can under-estimate blood loss. I therefore find that this under-estimation of blood loss does not in itself represent substandard care.

168. This inevitably means that it was acceptable not to diagnose a PPH at 01.25. No criticism therefore can attach to Nurse Wright for failing to initiate the PPH Protocol at this time by, for example, calling for obstetric assistance.

169. I am further satisfied that Nurse Wright’s response to the blood loss as estimated was entirely appropriate. In discussion with the CNM, she administered an additional dose of syntocinon. As this step is specified on the midwifery proforma, it is clearly a reasonably routine step which does not require obstetric input.

170. In summary, I am therefore satisfied that care at 01.25 complied with the standard of approach.

Blood loss event at 02.00

171. Dr. Lenehan acknowledges that, if the full extent of the plaintiff’s blood loss had been recognised at 02.00 this would probably have led to diagnosis of a major PPH requiring escalation in accordance with the IMEWS, RCOG or NICE Guidelines. It seems that several of the therapeutic measures identified by these guidelines (and by the experts in this case) were either taken or already in train by 02.00; for example intravenous access, urgent venipuncture, observations every 15 minutes and crystalloid infusion to restore circulatory volume. First line uterotonics in the form of syntocinon was also administered.

172. However, other measures such as summoning obstetric and anaesthetic assistance and considering second line prostaglandins, tranexamic acid and blood transfusion were not actioned. This was because the plaintiff’s likely blood loss was not thought to be over 1000 mls. Therefore, whilst in all likelihood the plaintiff had sustained a major PPH, it was nonetheless diagnosed and treated as a minor PPH. This in turn was due to the original underestimation of blood loss at 01.25.

173. I accept that on the facts of this case, the failure to take these measures does not constitute substandard care. The purpose of these measures is of course to stem blood loss and stabilise the patient. Here, the plaintiff recovered rapidly without needing further intervention. Her bleeding was controlled with syntocinon alone; her BP had started to recover by 02.10 and had virtually fully recovered by

02.20. Dr. Chavez, who was in the room at 02.00, records that haemostasis was achieved. Nurse Wright’s 02.00 note records that BP was normal on two different observations, that bleeding had settled, that the plaintiff was asymptomatic and that her uterus was well contracted. The plaintiff was also noted to be breastfeeding her baby. None of this indicates a need for escalated care.

174. Dr. Lenehan agrees that the RCOG Guidelines would also have indicated a group and screen and a full coagulation profile. However, I accept that, because the plaintiff responded very well, it was reasonable not to embark on further treatment or investigation at that time.

175. Likewise, whilst both the IMEWS and the RCOG Guidelines recommend summoning obstetric and anaesthetic staff, if bleeding is stemmed and the patient quickly stabilised, then there is little to be gained in urgently summoning additional staff.

176. Dr. Ashe and Ms. Coleman are highly critical of the inconsistency between the two BP readings recorded on the continuation notes at 02.00 (which were normal) and the reading recorded at the same time on the IMEWS chart (which is concerningly low). This inconsistency is quite glaring, and it is difficult to understand the sequence of events from the medical records alone.

177. On the other hand, the IMEWS BP reading was an outlier which conflicts with the two simultaneous observations recorded in the continuation notes. There are a range of possible explanations as to how this could occur such as, for example an improperly implied BP cuff or a vasovagal episode.

178. Overall, I accept Dr. Lenehan’s opinion that the hypothetical requirement to escalate matters on foot of the IMEWS BP reading was not corroborated by simultaneous observations or by developments which quickly showed recovery. There was therefore no need to summon additional personnel.

179. As such, whilst I accept that the plaintiff’s blood loss was under-estimated, I find as a fact that the treatment actually afforded to the plaintiff was effective and reasonable to address the clinical scenario presenting. I accept that Nurse Wright and her CNM were entitled to exercise their clinical judgment as to how to deal with the blood loss and the low BP reading without calling for obstetric review. It was therefore acceptable at that time to note the plaintiff’s very quick response to treatment with additional syntocinon and continue to monitor her closely.

180. I also accept Dr. Lenehan’s view that, even if obstetric personnel had been summoned at 02.00 she would in all likelihood have been treated with syntocinon only. One would only have proceeded to second line medication in the case of a further bleed. I find that this view is supported by the RCOG Guidelines. These state that uterine atony is the most common cause of primary PPH and that the initial management of PPH should therefore involve measures to stimulate uterine contractions. The Guidelines go on to recommend that a series of mechanical and pharmacological measures are instituted in turn. This supports Dr. Lenehan’s opinion that it is reasonable to proceed in the first instance by treating uterine atony with syntocinon.

181. Dr. Ashe’s opinion is that an obstetrician would have treated the matter with more urgency. Specifically, they would have administered second line prostaglandins which, on balance would have prevented the plaintiff’s subsequent two bleeds at 03.15 and 03.25.

182. These competing views represent two potential schools of thought as to what course of treatment should have been adopted at 02.00, the more conservative one favoured by Dr. Lenehan or the more interventionist favoured by Dr. Ashe. As such, the fourth and fifth Dunne principles apply and “a professional exercising reasonable care may adopt one of [these two schools of thought] even though there may be others who would take a different course."

183. In any event, given that syntocinon was effective in stopping bleeding and restoring uterine contractions, I am perfectly satisfied that taking the more conservative course of treatment accorded with the standard of approach.

Blood loss events at 03.15 and 03.25

184. For the reasons just explained, I am not persuaded that if obstetric assistance had been summoned at 02.00 this would have altered management in such a way as to prevent the two smaller bleeds at 03.15 and 03.25.

Summary of conclusions in relation to blood loss events

185. It is now apparent that blood loss was underestimated at 01.25 and that, in all likelihood the plaintiff suffered a major PPH. However, Nurse Wright’s failure to recognise this at the time did not represent substandard care. Whilst I accept that the IMEWS system would recommend that obstetric staff were summoned at 02.00, the situation was very quickly regularised. In any event, I am not convinced that had obstetric or anaesthetic staff been summoned they would have taken a different course to that followed by Nurse Wright. As such, the blood loss events at 03.15 and 03.25 were unavoidable.

Overall conclusion in relation to the management of the plaintiff at the Coombe

186. Dr. Ashe accepts that when Dr. O’Higgins attended at 03.30, she brought clarity to the situation and that her diagnosis and treatment of the plaintiff were appropriate. Therefore even if, contrary to my findings above, the Coombe’s response to the bleeds at either 01.25 or 02.00 was substandard, this resulted only in a delay of approximately an hour (02.30 to 03.30) in appropriate treatment being administered.

187. Dr. O’Higgins considered the possibility of RPOC but ultimately concluded that uterine atony was a more likely explanation for the plaintiff’s primary PPH. Dr. Ashe makes no criticism of this. Nor does he ultimately criticise her for not reexamining the plaintiff’s placenta which, he accepts, is not invariably required.

188. It is common case that after Dr. O’Higgins’ intervention, the plaintiff’s observations and vital signs were overall reassuring. Blood loss was minimal, the plaintiff’s uterus was well contracted and she was clinically well.

189. Finally, I emphasise that whilst the plaintiff’s experts criticise the lack of urgency in the plaintiff’s management at the Coombe at 02.00 (and to an extent at 01.25), no particular issue is taken with her management thereafter. Rather, the Coombe reasonably concluded that the cause of the plaintiff’s primary PPH was uterine atony which was managed in accordance with standard practice. The plaintiff’s experts do not criticise the Coombe for discharging the plaintiff with advice to return if she had any concerns. This, of course means that the plaintiff’s distressing collapse at home on 04.11.19, and all subsequent events, are unrelated to the alleged negligence of the Coombe’s behalf.

The MRH: management of secondary PPH

Standard of approach: conservative or surgical management

190. As stated above, Dr. Ashe primarily criticises the MRH for permitting protracted conservative management of the plaintiff’s secondary PPH. His view is that the MRH ought to have performed an ERCP after the plaintiff’s admission on

04.11.19 rather than exposing her to an uncontrolled risk of bleeding in the community. By contrast, in light of the risk of uterine perforation, Dr. Lenehan was adamant that conservative management was the only reasonable approach and that it would have been unwise to perform an ERCP earlier than occurred in this case.

191. It is not necessary to choose between the testimony of these experts because Dr. Ashe ultimately conceded that adopting the conservative approach was within the band of reasonable management, provided that same was discussed with the plaintiff and her informed consent obtained. Whilst he feels that Dr. Lenehan somewhat overstates the risk of uterine perforation in this case, Dr. Ashe accepted that it is a judgment call as to whether to take the conservative route or to carry out an invasive clinical procedure.

192. I therefore find that the standard of approach to be applied to the MRH permits of two schools of thought, surgical intervention as favoured by Dr. Ashe and conservative management as favoured by Dr. Lenehan. In accordance with the fourth and fifth Dunne principles, the MRH was entitled to exercise its clinical judgment and adopt one of these two schools of thoughts even though there may be others who would take a different course.

193. Naturally, the informed consent of the plaintiff to either course of management ought to be obtained. Dr. Ashe outlined the consenting process that one would expect if the conservative approach were to be adopted. One should explain the risks of uterine perforation in the event of surgical intervention as against the risk of possible uncontrolled bleeding in the community with the conservative approach. Dr. Lenehan did not demur, save to state that the clinician ought to emphasise the danger of ERCP which, it is common case, is considerably greater in the early post-partum period.

Did the MRH comply with the standard of approach in its management of the plaintiff?

194. Dr. Ashe acknowledged that it was reasonable for Dr. Maher to make an initial differential diagnosis of either endometritis or clots/ RPOC. Specifically, certain features of the plaintiff’s presentation such as; tenderness in the lower abdomen, and raised white cell count/ CRP were indicative of endometritis, which is a known cause of secondary PPH. It was reasonable to treat the plaintiff for this condition whilst also treating the second aspect of the differential, uterine atony due to RPOC.

195. Further, despite criticising the ultrasound taken on the 05.11.19 in his report, Dr. Ashe acknowledged that it is notoriously difficult to distinguish between clot and RPOC on ultrasound.

196. I therefore find that the MRH’s conservative approach was within the standard of approach. Dr. Maher was entitled to make the judgment call that she did and opt for conservative management, provided same was discussed with the plaintiff and she consented thereto.

197. Dr. Ashe no longer strongly contends that the MRH adopted an inappropriate course of management. Rather, he now suggests that the plaintiff’s informed consent as between two reasonable alternative courses of management was not obtained. However, this would only give rise to a cause of action if the plaintiff satisfies the court on the balance of probabilities that, if offered a choice between conservative and surgical management, she would have opted for the latter.

198. The plaintiff did not give testimony to this effect. Indeed, this issue was not expressly addressed in either direct or cross examination. However, much of the plaintiff’s testimony suggests that she would have favoured the more conservative/wait and see approach. The plaintiff understood that there was matter in her uterus which needed to be evacuated and that was the purpose of the uterotonic medication. There is nothing to suggest that she enquired about, or requested, more definitive treatment. In her history to Prof. Thakore, the plaintiff identified the requirement to undergo ERCP as the “stressor” for her subsequent adjustment disorder. This suggests that she is likely to have been keen to avoid ERCP if at all possible.

199. I can see no evidence whatsoever to support a finding that if the risk of uterine perforation had been explained to her, the plaintiff would have opted for surgical management during the course of her admission between the 04.11.19 and 06.11.19 (even if it had been appropriate to offer same).

200. This remains the position on 17.11.19. In the interregnum between the

06.11.19 and 17.11.19,the plaintiff experienced only period-like bleeding. This is most unlikely to have encouraged the plaintiff to opt for ERCP.

201. Whilst the plaintiff’s bleeding appears to have become heavier between the

17.11.19 and the 26.11.19, it is not disputed that on the latter date, the relevant options of proceeding conservatively, medically or surgically were discussed with her. It appears that on this date the plaintiff agreed to wait a further week in the hope that the uterotonic agents would be effective. This again suggests that the plaintiff would not have opted for ERCP at any earlier point in time.

202. Overall, I am satisfied that the MRH adopted a reasonable course of conservative management. Whilst I did not have details as to the precise consent discussions with the plaintiff on 04.11.19 or 17.11.19, I am not satisfied on the balance of probabilities that she would have opted for surgical management even if it had been appropriate to offer same on either of those dates. I am further satisfied that the option of surgical management was specifically discussed with the plaintiff on 26.11.19 and that she elected for a further week of conservative management. I can see no substandard care in any of the above.

203. I accept that it is unsatisfactory that the two-week ultrasound scan scheduled by Dr. Maher on the 06.11.19 did not occur. However, the plaintiff represented to the MRH before the expiry of this two-week period in any event. I further accept that even if a further ultrasound had been carried out around this date, it is unlikely to have reliably discriminated between clot on the one hand and RPOC the other. Nothing therefore turns on the unfortunate failure to organise this ultrasound.

CONCLUSION

204. In conclusion, I find no clinical negligence on the part of either the Coombe or the MRH. I should further say that, even if negligence were established, I am not satisfied that the adjustment disorder unfortunately suffered by the plaintiff resulted from any such negligence. As described by Prof. Thakore, the cause of the plaintiff’s adjustment disorder was the requirement to undergo ERCP. As matters transpired, this was unavoidable irrespective entirely of the actions of either the Coombe or the MRH.

205. Whilst this is undoubtedly an unfortunate case, in which the plaintiff suffered a primary and secondary PPH, both of which were caused primarily by RPOC, I am unable to identify any negligence on the part of either hospital. Accordingly, I must dismiss the plaintiff’s case.