The inquest into the death of Evelyn Flanagan, Hollyhill, Ballyheane, Castlebar was adjourned on Wednesday evening (September 24 ) by Coroner for South Mayo, John O’Dwyer, until December 1. The coroner adjourned the inquest after three days following an application by Mr John Jordan, legal representative for the deceased’s husband Mr Padraig Flanagan to retain expert independent evidence from an expert on amniotic fluid embolism (AFE ), which, according to the pathologist for Mayo General Hospital Dr Fandel Bennani, was what led to Mrs Flanagan death.
The coroner undertook to retain the services of an independent pathologist who had expert knowledge of AFE because it is such a specialised area and none of the doctors who gave evidence in the inquest could call themselves an expert in the area.
In his evidence to the inquest Dr Bennani said that he was 100 per cent confident in his diagnosis. During strenuous cross examination from Mr Jordan, Dr Bennani said that he had never come across a case before and that “this is my first and hopefully the last”. During the questioning Dr Bennani rejected claims put forward by Mr Flanagan through his counsel that his wife died because of blood loss she suffered after giving birth to her second child on October 18 2007. The pathologist said that if she died due to blood loss, there would have been changes to her kidneys, heart and brain, none of which he found.
The pathologist also revealed that he retained slides and photographs from the autopsy which had not previously been revealed to the family of the deceased, which was normal hospital policy. He said they were available to any third party for investigation. He also confirmed that Mrs Flanagan’s womb, which had been removed during an operation to stem her bleeding, was retained for three months following the completion of his report before being sent for incineration. Mr Jordan questioned him as to why his autopsy report said that no organs were retained when he held on to the womb. Dr Bennani told the inquest that the womb was a surgical specimen as it was removed during surgery, not during the autopsy. Mr Jordan also put it to the pathologist that the womb should have been retained until after the inquest so that Mr Flanagan could have it independently examined. Dr Bennani replied it was hospital policy to hold on to all surgical specimens for three months after his report in case anyone wanted to question it, but after three months they were all sent for incineration.
At the start of the inquest Mr Padraig Flanagan told the inquest that serious questions remained to be answered in relation to his wife’s death and he outlined 43 different questions that he wanted answered. He told the inquest that he believed his wife would be alive today if proper care and attention was given to her. According to the doctors who gave evidence, Mrs Flanagan died from AFE, which happened after a spontaneous uterine tear which occured during birth and the amniotic fluid which escaped through this tear caused her to have a massive pulmonary thrombosis. Mr Flanagan told the inquest that he noticed his wife was lying in a bed saturated with blood which was dripping on to the floor. Mrs Flanagan gave birth at 12.30pm on October 18 after being induced as she was 12 days overdue. According to Mr Flanagan his wife bled heavily afterwards, between 1pm and 2pm and the monitor to measure her blood pressure kept beeping and he had to bring it to the attention of a member of staff himself. This claim was denied by hospital midwife Kathy Hegarty, who was Mrs Flanagan’s midwife, and who told the inquest she would have stayed with her all the time, until she handed care over to another midwife, Mary Devers, when she went on a break.
Mrs Flanagan continued to bleed from the tear and it wasn’t until 4pm that day that she was brought to theatre to have a laparotomy. Dr Mohamad, the private consultant obstetrician/gynaecologist who the Flanagans had retained, identified the source of the bleeding and a hysterectomy was performed before the bleeding was stopped. During the operation Mrs Flanagan arrested twice and the medical staff did not discover the reason for this until the pathologist filed his report.