Woman's inquest records medical misadventure after she died using HSE home-birth service

David Raleigh

HSE home-birth services remain paused across the Mid-West region following the death of a woman who suffered complications after giving birth to her first child, at her home, her inquest heard Wednesday.

Laura Liston (36) had dreamed of becoming a mother, but she died a number of hours after delivering her son in a birthing pool, using an HSE home-birth service, at her home, at Dunnaman, Croom, Co Limerick, on June 5th, 2022.

The pregnancy followed on from successful IVF treatment, heard the inquest held at Limerick Coroners Court, Kilmallock.

Ms Liston opted for a home birth in accordance with HSE protocols and was deemed suitable for the service despite an issue with her placenta which was discovered earlier in her pregnancy.

A verdict of medical misadventure was recorded by coroner John McNamara.

On the day she delivered her son, Shay, Ms Liston was being assisted by two self-employed community midwives contracted by HSE Mid West.

Giving evidence, Ms Liston’s husband, Fergal Mannion, broke down as he described how the couple had been "over the moon” when his wife became pregnant after the had previously experienced difficulties conceiving a child.

“We were delighted to be starting our home and family. All she ever wanted was to be a mother,” said Mr Mannion.

He said they got married in 2019 and had been living in a mobile home on the site of where they were building their family home.

Ms Liston was giving birth under the HSE home-birth guidelines and was using a birthing pool to assist with easing of any pain.

Ms Liston’s waters broke on the morning of June 4th and she was overjoyed when she delivered her son in the pool that night.

The inquest heard that at the time giving birth in a pool was contrary to HSE guidelines.

However, shortly after giving birth in the pool Ms Liston began to experience bad pain while attempting to deliver the afterbirth or placenta.

Mr Mannion said at this stage his wife stood up in the birthing pool and fainted and their baby son fell into the pool but was not injured.

Mr Mannion said he was assured by the mid wife that his wife was fine. He said his wife was brought to a nearby couch, and in his opinion she “did not look well”.

Mr Mannion, who was holding his newborn son, said he saw blood in the birthing pool and that his wife was complaining of being in pain, feeling faint, vomiting and asking for an ambulance.

Sandra Healy, who was the primary contracted midwife with Ms Liston at the time, stated that “in hindsight” she could have alerted the hospital earlier due to Ms Liston’s complaints.

Professor Amanda Cotter, a consultant OBGYN, UMHL, gave evidence that if it had happened in a hospital setting it would have been treated as an “emergency”.

The two midwives did eventually call the emergency services, and two ambulances arrived at Mr Mannion and Ms Liston’s home.

One ambulance ferried Ms Liston to University Hospital Limerick (UHL) and the other took Mr Mannion and his newborn son to University Maternity Hospital Limerick (UMHL) which is located on a separate site.

While at UMHL, Mr Mannion was informed his wife had been brought to UHL a few kilometres away and when he went there he was told she had died.

“I wish I could have been by her side,” Mr Mannion stated in his deposition to the inquest, which had to be completed by Ms O’Sullivan after he broke down in the witness box.

The hearing heard Ms Liston died from haemorrhage and shock due to a uterine inversion which is a rare and life threatening complication associated with child birth.

After the inquest a statement by the deceased’s family was read by their solicitor, Scarlett Griffin O’Sullivan, which argued “this tragedy was avoidable and should never have happened”.

“Laura should be here fulfilling her dream. As a mother to her beautiful son and wife to Fergal, she has missed and will miss all of her son’s milestones,” said Ms O’Sullivan.

“The inquest highlights the urgent need to ensure basic clinical standards and protocols are followed in maternity care, which were unfortunately lacking in Laura’s case with fatal consequences,” she added.

Mr Mannion stated that his life “stopped” the night his wife died and he had been left “haunted” by it all.

He said he continues to experience “panic attacks” and is traumatised that his wife is not alive to continue to experience and share in their son’s life.

He said he and his family’s lives had been “shattered” by her death.

A letter of unreserved apology from the HSE for its “failings in care”, in respect of Ms Liston’s death, was read out by senior counsel Oonah McCrane, on behalf of HSE Mid West.

The HSE said Ms Liston and her family had trusted that she would have been safe in the hands of the HSE services on the day “and that trust was broken”.

The apology said that learnings and improvements had been put in place but it acknowledged that this was of no comfort to a grieving family.

The HSE Mid West home birth service across Limerick, Clare and north Tipperary has not resumed since Ms Liston’s death.