On the 24 February last, Bernard Fitzpatrick, Tracey’s widower, and James and Pauline Campbell, Tracey’s parents, stood on the High Court steps after the HSE had apologised in full to the family for
Tracey’s death which occurred on Easter Monday 2016. Tracey died just a few hours after giving birth to her son Max in St Luke’s Hospital Kilkenny.

At the inquest into Tracey’s death held in October 2017, a pathologist, Dr Peter Kelehan presented his conclusion from his postmortem findings that Tracey had suffered from amniotic fluid embolism
syndrome (AFE) which he said was an ‘unpredictable, unpreventable and very rare’ condition (RTE, 2017 https://www.rte.ie/…/912201-tracey-fitzpatrick-inquest/). The jury and the coroner agreed with his conclusion and the coroner’s verdict was death from natural causes as a result of AFE.
(https://www.independent.ie/…/tracey-was-a-real-lady-who…).

Tracey’s widower and family disagreed with this verdict and sought expert advice outside Ireland.

Almost five full years since her death, the High Court heard last month that the HSE, faced with overwhelming evidence to the contrary from an international expert on AFE, had withdrawn completely its argument that AFE had been the cause of Tracey’s death. Instead they accepted that Tracey died following irretrievable failings in her care which led to a massive postpartum haemorrhage. On this basis, the HSE and the hospital issued an apology and made a financial settlement to Tracey’s children (https://www.rte.ie/…/1199072-courts-settlement-hse…/).

Outside on the court steps, Tracey’s father read aloud a statement emphasising how difficult a time the family has had in getting to the truth:
‘Referring to an admission of liability in the case, Mr Campbell said the family had been put through hell for the past five years in their fight “for this truth.”
https://www.independent.ie/…/this-will-not-bring-our…

On the 25th February, Bernard, Tracey’s widower gave a moving interview to RTE’s Sarah McInerney on Drivetime in which he said:
‘The Coroner’s court .. to come out and say she died of natural causes was very, very hurtful .. this AFE finding .. so we had to take that finding on that day .. but we went off and we got the world’s best expert on AFE .. and he totally threw out the idea of AFE, he said no possible way’
(https://www.rte.ie/radio/radioplayer/html5/#/radio1/21914934

Now that the HSE has retracted its position on the cause of Tracey’s death, there is one further important administrative dimension to this tragedy that requires attention.
In 2007, in a letter to the Irish Medical Journal, two senior obstetricians, Drs Murphy and Herlihy commented that maternal mortality statistics are crucial indicators of women’s reproductive health care but that there was a problem in Ireland with the collection of data and thus with the overall reliability of Irish maternal death statistics

(Letter, Maternal Mortality Statistics in Ireland: Should They Carry a Health Warning? Irish Medical Journal, 2007, September, 100 (p. 574).

The problem of uneven data collection of these statistics was gradually rectified following the move
in 2009 to establish the Maternal Death Enquiry as part of the National Perinatal Epidemiology

Centre in UCC, funded by the HSE. Since that time, the MDE has been publishing triennial bulletins on the numbers and causes of maternal deaths in Ireland.

The verdict of the 2017 inquest, death from natural causes as a result of AFE, would have been recorded as such on hospital records and/or forwarded directly from the coroner’s office to the MDE team in UCC and would have formed part of the data going into the MDE’s triennial report for 2015-2017. That finding of AFE which is incorrect must now be corrected to accord with the High Court ruling of 24th February.

Again we offer our heartfelt sympathy to Bernard Fitzpatrick, Tracey’s sons, and the Campbell family and we salute their courage to seek the truth of Tracey’s death.

Jo Murphy-Lawless, The Elephant Collective, 8 March, 2021.