MEDICAL NEGLIGENCE PATIENT SAFETY ITEM 1.9

PATIENT SAFETY ACT 2023

John Whelan Solicitor with specialist expertise in Medical Negligence and Patient Safety gives an example of a Notifiable Incident as envisaged by Item 1.9 of the Act. 

There are 13 notifiable incidents set out in the Act but other notifiable incidents may be introduced by Ministerial regulation under Section 8 of the Act.

Item 1.9

This example of an unanticipated death of a woman during pregnancy that could occur due to the negligence or mismanagement of a medical team:

Case Example: Postpartum Haemorrhage (PPH)

A woman was admitted to a hospital for the delivery of her second child. The pregnancy had been uneventful, and she delivered a healthy baby vaginally.  Shortly after delivery, the Patient began to experience heavy bleeding (postpartum haemorrhage), a known complication after childbirth.

The nurse noticed the bleeding but underestimated its severity, assuming it was normal postpartum bleeding. The attending doctor was called, but delayed assessing the situation due to being occupied with another patient. When the doctor finally arrived, the doctor ordered medication to stop the bleeding but did not perform a proper uterine examination to check for retained placenta, which is a common cause of haemorrhage.

Over the next hour, the Patient’s condition worsened, and her blood pressure dropped significantly. The medical team did not respond with adequate urgency, delaying further interventions like blood transfusions or surgical intervention (such as a uterine evacuation or hysterectomy). The Patient eventually went into shock due to blood loss and suffered cardiac arrest. Despite resuscitation efforts, she died shortly afterwards.

In this case, the death was unanticipated and could be attributed to medical mismanagement due to:

1. Failure to promptly assess the severity of the haemorrhage.
2. Delay in administering appropriate treatment.
3. Lack of proper monitoring and escalation of care when her condition worsened.

Had the medical team acted swiftly and followed established protocols for managing postpartum haemorrhage, the Patient’s death could have been prevented.

For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/