Following the death of Tracey Campbell- Fitzpatrick at St Luke’s Hospital, Kilkenny in 2016, her family engaged in a lengthy process to achieve some form of accountability from all those involved. Her father, James Campbell, had criticised the HSE and St Luke’s for putting his family “through hell” over five years in their fight for the truth “until they were faced with overwhelming evidence they could defend no longer.” That truth resulted in the HSE and St Luke’s General Hospital admitting liability for her death and issuing an “unreserved apology” for the “failings in the care” of the young mother in the hospital.
Tracey Campbell-Fitzpatrick died following a massive loss of blood, just hours after giving birth to her second child. An inquest had returned a verdict of death by natural causes, however her family challenged that verdict and contended that if an earlier intervention had been made, her life could have been saved. After five years, the HSE and St Luke’s admitted liability.
Today, 20th February, the consulting obstetrician and gynaecologist responsible for overseeing her care admitted to charge of professional misconduct and poor professional performance over his failure to attend Campbell-Fitzpatrick in a sufficiently timely manner when he knew her clinical condition required his attendance at the hospital on the night her death, during a Fitness to Practice Tribunal held in public by the Medical Council of Ireland.
The tribunal heard that Dr David McMurray had taken over 40 minutes to arrive at St Luke’s after being 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 and despite having been notified by a midwife about the patient’s deteriorating health after delivering her baby.
While the Tribunal noted that under this process there is no allegation that the delay in this case caused Ms Campbell’s death – it noted had Dr McMurray arrived in a timely manner there may have been a different outcome.
Counsel for the IMC, Neasa Bird BL, said a more timely attendance would have given the patient “the best possible chance of a positive outcome.”
Bird said Dr McMurray originally maintained that the call he received was just to inform him that Campbell Fitzpatrick had given birth and was in a poor condition. However, the consultant now accepted that a decision had been taken to bring the patient to an operating theatre during the call.
However, the family have to wait a bit longer to find out what the sanction imposed on Dr McMurray will be, almost seven years after the death of Tracey Campbell-Fitzpatrick as any recommendations from the Fitness to Practice inquiry must go to the full Medical Council before announcement.
In determining the sanction, Frank Beatty, legal advisor to the IMC pointed out that a number of options are available from censure all the way to being prohibited from practicing. He advised that a number of considerations including the safety of the public, deterring the practitioner from repeating, and ensuring the upholding of good practice by other members of the practice. In consideration, he advised that the Committee had to afford the registrant as much leniency as possible while upholding the considerations above, and that they should consider mitigating matters such as whether the event was a once off, whether the consultant has an unblemished record, and demonstrates remorse and ‘insight’.
While the inquiry was scheduled to last through the week, from Monday to Friday, the acceptance of the charge of professional misconduct by the Dr McMurray from the outset provides some relief to the family of Tracey Fitzpatrick having had to battle the apparatus of the State for seven years to find some form of accountability.
After the HSE and St Luke’s finally admitted liability in 2021, the father of Ms Campbell-Fitzpatrick stated: “The HSE and the hospital have put us through hell for the past five years in our fight for this truth. They have denied the truth, defended the indefensible and delayed the progress of our legal battle every step of the way until finally they were faced with overwhelming evidence they could defend no longer. The truth is all that matters now.”
The story of Tracey mirrors that of the arduous process encountered by the family after the death of two-day-old Laoise Ní Scolaí in the Coombe Hospital in January 2015.
Her father, Cóilín Ó Scolaí spoke last week of the his family was treated and the betrayal of trust they experienced after the death of their newborn child. He said he and his wife, Irene Kavanagh, had only uncovered the truth about what happened after a tremendous fight on their part and that something needed to change to prevent other families going through the same thing. In their opinion, the medics cared about Laoise until the moment she died, but then they cared more about the reputation of the Coombe Hospital.
Seven years seems to be the time required of Irish citizens to find justice when the lives of their loved ones are lost in the Irish health system.
After 5 years of being put through hell, the family of Tracey Campbell-Fitzpatrick have fought a lonely battle to move beyond corporate liability, where the HSE and hospital are held responsible, to determine a level of individual responsibility.
Speaking after the HSE admittance of liability reported on extra.ie in 2021, Mr Campbell spoke about what he wanted:
‘Truth and accountability are the only two things that matter. If you don’t have accountability, you will have the same mistakes being carried out and people don’t really care,’
‘In my daughter’s case, a perfectly healthy young woman went into hospital for one of the most natural things, to have a baby, in a modern hospital with highly trained staff and she comes out in a coffin two days later. There is something wrong there.’
‘If those people are not held accountable, this is going to continue. That’s the awful thing about it.’
Finally, some accountability may be had for the Campbell and Fitzpatrick family. However, questions remain as to why, after enduring the loss of a dear family member, they are forced into repeated adversarial processes, drawn out over many years, to achieve that accountability.
Story after story crop up as the government, the HSE, and each hospital, engages their massive resources to protect institutions that are supposed to serve the public. Each investigation follows the same tired pathway. The institution attempts to drain the resources and the energy of those who have already lost enough, dragging them through the courts, before, upon realising the complainants are not going away, admitting liability once there is no other alternative.
Finding out the truth of misadventure in the health service is in the public interest. The State should not be able to obstruct the quest for truth by trying to outspend and outlast its victims and their families in the courts. Until this changes, there is no real accountability of the government to its people.
The battles fought by the Campbell-Fitzpatrick family, by the Ó Scolaí family, and by many others are a public service. They should not have to drive themselves to bankruptcy to carry out that service. It should not be for retired grandparents like James Campbell to have to dedicate their years of rest to fighting the State to achieve justice and accountability after already having suffered an unimaginable loss.
Whether the outcome and the recommendations that come from the Fitness to Practice Tribunal today provide some succour to the family, no admittance of liability and nor an admittance of professional misconduct will return their loved ones to them. Nor will they get back the years that have been forced to spend seeking justice.