A hospital consultant has been found guilty of professional misconduct over his delay in returning to hospital while on-call to attend to a young Carlow woman who died shortly after giving birth at St Luke’s General Hospital in Kilkenny seven years ago.
A fitness-to-practise inquiry of the Irish Medical Council also found consultant obstetrician and gynaecologist, David McMurray, guilty of poor professional performance over his failure to attend to the patient in a timely manner.
The inquiry heard it had taken over 40 minutes for Dr McMurray to arrive at St Luke’s after he was alerted of the need to bring the patient to theatre to deal with extensive postpartum bleeding, despite living just 5-8 minutes away from the hospital.
Tracey Campbell Fitzpatrick (36) – from Nurney, Co Carlow but originally from Knock, Co Mayo – bled to death from a massive haemorrhage within three hours of giving birth to her second child, a boy named Max, on March 28th, 2016.
On-call consultant
Dr McMurray, who was the on-call consultant on the night, admitted a charge of professional misconduct over his failure to attend Ms Campbell Fitzpatrick in a sufficiently timely manner when he knew her clinical condition required his attendance at the hospital.
The inquiry heard Dr McMurray only arrived at St Luke’s at 2.20am, despite having first been notified by a midwife at 1.38am about the patient’s deteriorating health after delivering her baby.
Two other calls about the patient were also made to the consultant at 1.58am and 2.08am.
Dr McMurray, who qualified as a doctor from Queen’s University in Belfast in 1992 and previously worked in the UK before moving to Ireland in 2013, also admitted to a separate charge of poor professional performance over his failure to attend Ms Campbell Fitzpatrick in a timely manner.
Counsel for the IMC, Neasa Bird BL, said the inquiry arose as a result of a complaint made by the patient’s husband, Bernard Fitzpatrick, who had recalled how his wife was a healthy active woman looking forward to the birth of her second child.
She was admitted to St Luke’s on March 26th, 2016 as she was three days over full term and had elevated blood pressure.
A decision was taken to induce her the following day, Easter Sunday and her son, Max, was born at 12.55am.
Cardiac arrest
The hearing was told that Ms Campbell Fitzpatrick had collapsed in a lift on the way to theatre at around 1.55am after experiencing heavy bleeding after the birth and suffered a cardiac arrest during surgery at 2.30am.
In his complaint, Mr Fitzpatrick described how medical staff were “in a panicked state” after her collapse in the lift and how he had to walk over a large pool of dark blood from his wife on the floor which was up to 4ft in diameter.
He also remarked: “It was much too late to save her. She had lost too much blood.”
She was formally pronounced dead at 3.45am.
Ms Bird said Dr McMurray originally maintained that the call at 1.38am was just to inform him that Ms Campbell Fitzpatrick had given birth and was in a poor condition.
However, Ms Bird said the consultant now accepted that a decision had been taken to bring the patient to an operating theatre during the call.
She said the admissions made by Dr McMurray constituted a serious falling short of the standards of conduct expected of a doctor.
Ms Bird said a more timely attendance would have given the patient “the best possible chance of a positive outcome.”
An inquest into Tracey’s death in 2017 recorded a verdict of death due to natural causes – a finding that her family subsequently disputed after they commissioned a series of expert reports into her care by medical staff at St Luke’s.
Ms Bird said a condition which was attributed to causing her death, an amniotic fluid embolism, was regarded in the expert reports as a contributory factor but not the immediate cause of her death.
A report by an expert witness for the IMC, Professor Michael O’Connell, concluded that Dr Mc Murray should have been more proactive in attending to the patient in the hospital given his knowledge of her condition and the number of calls made to him about her case.
Testimonials
Counsel for the consultant, Cathal Murphy BL, said it was important to stress that Dr McMurray, who no longer works at St Luke's, did not face any allegation that his delay in getting to the hospital had resulted in Ms Campbell Fitzpatrick’s death.
A large number of testimonials from fellow medical professionals were also read out on Dr McMurray’s behalf including one which observed that he was a “careful, diligent doctor.”
Another described him as an “excellent practitioner” and “a consummate professional for exceptional patient care.”
Mr Murphy also offered his condolences to Ms Campbell Fitzpatrick’s husband and relatives for “these unfortunate events.”
While errors had been made in the care of the patient, Mr Murphy said the testimonials indicated they were “uncharacteristic” of his client and he believed the appropriate sanction in the case should be one of “censure.”
However, Ms Bird said censure would not meet the seriousness of the underlying findings against the consultant, and she recommended that conditions should be imposed on Dr McMurray’s continued registration as a doctor “at a minimum.”
Following its findings of professional misconduct and poor professional performance, the FTP committee chairperson, Joe McMenamin, said its recommended sanction in the case would not be made known in public as any decision is made by the full Irish Medical Council.
In 2021, the High Court approved a settlement for Ms Campbell Fitzpatrick’s family, which included a payment of €700,000 for the care of Max, after the HSE and St Luke’s General Hospital admitted liability for her death.
The two parties also issued an “unreserved apology” for the “failings in the care” of the young mother in the hospital.
