I raise a matter of public importance, which is the need for the Minister for Health to establish an independent inquiry into the death of Malak Thawley in the National Maternity Hospital, Holles Street on the 8 May 2016. Representatives of the family have requested that I bring this emotional and personal matter to the floor of the Dáil.
Malak Thawley, who was living in Blackrock, was a 35 year old teacher who was expecting her first child with her husband Alan. An ectopic pregnancy was diagnosed at seven weeks and she required urgent surgery in the National Maternity Hospital. After surgery commenced, the abdominal aorta was torn by a bladed trocar. It took 55 minutes to identify this while an acute vascular haemorrhage was occurring on the theatre table.
A series of catastrophic and shocking errors then occurred. The consequence of these and the failure to follow basic protocol resulted in the death of Malak Thawley by medical misadventure as outlined by the verdict of the coroner. The significant cause of concern for the family, and for the public, is the contradictory evidence and information from the internal hospital inquiry and the facts as established by the coroner.
The hospital conducted an internal review of this tragic death by medical misadventure but following on from the considered and probative questions the family feels that crucial, vital and extremely revealing new facts, events and incidents have only now come to light. The family sees the internal hospital review as a shambolic attempt to hide crucial facts and salvage reputations. For public confidence, trust and transparency where serious adverse incidents occur we cannot allow hospitals to investigate themselves in this way.
There are a number of questions that illustrate the complete contradiction of evidence between the public coroner process and the internal review. Why did Mr. Thawley have to find out through a public forum that there was no blood in the lab, not enough blood in theatre and that his wife’s blood group was not cross matched? Why was there not enough staff to ensure basic functions such as having a laparotomy kit ready? Why were only junior staff available to treat Malak as she was dying? Why was there no supervision, no co-ordination and no accountability? Why was there a complete and total breakdown of communication at all levels? Why were staff not experienced in all forms of laparoscopy technique? Why did the hospital choose not to explain the difference between bladed and unbladed trocars in its internal investigation? Why was it never explained to Mr. Thawley that there was a recognised safer option of using the unbladed trocar? Why and how could it be that there was no consultant on site in the event of an emergency? Why did senior members of staff have their phones switched off or on silent? Why was it that ice for lifesaving cooling treatment had to be obtained from a nearby pub and why was this not explained clearly in the internal report? Why was there a lack of adrenaline available? Why did a Garda escort have to be arranged to procure other medical devices from another hospital? Why was there contradictory evidence provided by witnesses at the coroner’s inquest?
Some of the Minister's remarks in his correspondence to the family have disappointed them and while they acknowledge the Minister's expression of regret and sympathies, as the Minister for Health his correspondence referenced the future changes and the proposed move of the National Maternity Hospital to the St. Vincent's hospital site. In the family's view this is completely irrelevant to Malak's case. In his correspondence the Minister stated to the family “perhaps the inquest into the late Mrs. Thawleys tragic death and the investigation in the hospital have indeed established what went wrong”. The family interpret these remarks as completely insufficient and an implication that the inquest may be the end to the matter. This will not address the internal hospital systemic failures, accountability, full disclosure, transparency and what can be learned to prevent similar tragedies in the future.
The family has two specific and direct requests of the Minister. The first request is for the Minister to meet with them. What is the delay to that happening? The second request is that the family want to be able to tell the Minister why they believe that an independent inquiry is absolutely necessary. The family want to tell the Minister directly. Will the Minister agree to establish a public inquiry in the interests of a maternal hospital system and in the interests of this very tragic case?