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 today (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 at her home at Dunnaman, Croom, County Limerick, on June 5, 2022.
The pregnancy followed on from successful IVF treatment, the inquest held at Limerick Coroners Court in Kilmallock heard.
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 at her inquest.
On the day she delivered her son, Ms Liston had been attended 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 they 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 the two 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 4, 2022, and she was overjoyed when she delivered her son that night.
The inquest heard that at the time giving birth in a pool was contrary to HSE guidelines.
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.
He said he was assured by the midwife 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 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, 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 at University Maternity Hospital Limerick (UMHL), gave evidence that if such an incident 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 the couple’s home.
One ambulance ferried Ms Liston to University Hospital Limerick (UHL) and the other took Mr Mannion and his newborn son to UMHL.
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, which had to be completed by his solicitor, Scarlett Griffin O’Sullivan, after he broke down in the witness box.
The inquest heard Ms Liston died from haemorrhage and shock due to a uterine inversion which is a rare and life-threatening complication associated with childbirth.
After the inquest, a statement by the deceased’s family was read by their solicitor, 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.”
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 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 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.