Monday, 4 November 2013

Inquest into the death of Bimbo Onanuga - Rotunda Hospital


In 2010, AIMS Ireland were contacted over the recent death of a woman in the Rotunda hospital in Dublin. We were asked to look into the woman's death and the circumstances in which the woman died due to their concerns regarding the care the woman received. The woman's name was Bimbo Onanuga.

The following is a summery of events to seek justice for her death.

Synopsis in Brief - Salome Mbugua CEO -AkiDwA

Bimbo Onanuga was a Nigerian woman, mother to Nellie who was born with severe cerebral palsy in Limerick Regional Hospital in 2003. Bimbo was Nellie’s fulltime carer. In 2010, Bimbo was pregnant with her second child. On 1 March, 2010, her GP referred Bimbo to the Rotunda Hospital with a suspected intrauterine death. Bimbo was seen in the hospital on the 1 March when the IUD was confirmed. She was told to return to the hospital on Thursday the 4 March for treatment. Bimbo was then over seven months pregnant.  Bimbo began to experience severe pain on the night of the 3 March and was taken to the Rotunda by ambulance.  Throughout that night and into the following day, Thursday the 4 March, Bimbo’s partner, Abiola Adesina, was increasingly alarmed at Bimbo’s deteriorating condition. He attempted repeatedly to raise his concerns with hospital staff, but felt that his warnings were ignored.  Bimbo was transferred in critical condition to the nearby Mater Hospital on the 4th March where she died later that night. 

Under current legislation, maternity hospitals and maternity units are required to report a maternal death to the local coroner’s office, but an inquest is not automatically forthcoming.  Internal inquiries are generally held in hospitals but their contents and findings are not necessarily disclosed to family members. More recently, since 2008, the HSE has instituted a national critical incident review policy, but these reports are not necessarily made public either.  On the basis of the hospital’s report to the Dublin City Coroner, the Coroner determined that there was no necessity to hold an inquest.

However, Abiola felt there were pressing questions about Bimbo’s care that were never responded to by the hospital and put in repeated requests to the coroner’s office about holding an inquest.  

The results of the Rotunda’s internal inquiry were not made public and it was only after parliamentary privilege was exercised on the floor of the Dáil by Clare Daly TD in May, 2011, that the HSE disclosed most, although not all recommendations arising from its inquiry into Bimbo’s death. Parts of that report were redacted. The HSE then issued a public apology to Bimbo’s partner and family via a press release but were not in direct contact with them. The family had not heard from the hospital nor the HSE from the time of Bimbo’s death, March 2010, up to the night the questions about the inquiries were answered in the Dáil in May, 2011.
The Dublin City Coroner has now gathered documentation and determined that an inquest be held and this will happen on the 18th April, 2013.

Bimbo’s daughter, Nellie, died in December 2010 as a result of complications with her cerebral palsy. Abiola is now in London where Bimbo’s brother also lives.

The presence of both Abiola and Bimbo’s brother at the forthcoming inquest is vital.  Abiola is owed a full and public hearing about the circumstances of Bimbo’s death. He will have full legal representation at the inquest.

Full Details Thus Far:

Correspondence with Rotunda Hospital regarding Maternal Death
In late April, 2010, AIMSI wrote to the Master of the Rotunda Hospital, Sam Coulter-Smith expressing concern in relation to the death in March, of Bimbo Onanuga, an Irish-Nigerian woman who was seven months pregnant and had been told days earlier that her unborn child had died. AIMSI raised several points of concern, including the responsibility of maternity hospitals to take into account the specific needs of migrant women, and the need for clear and empathic communication with women and their families.  While the response received was not specific to the case, AIMSI was pleased to receive a swift reply from Mr. Coulter-Smith acknowledging the importance of issues raised. AIMSI are aware that Amnesty International has expressed an interest in this case, in light of suggestions that race and ethnicity may have played a role in the care and treatment of Ms. Onanuga. The investigation was ongoing. While we tried to chase Sam Coulter-Smith for more information, we were told that nothing would be released.
Contact with the Coroner's office informed us that as Bimbo had died of 'natural causes' there would be no inquest.
The HSE said there would be not internal inquiry into Bimbo's death.
 Another Foreign National Maternal Death and an Irish Maternal Death....

On April 13, 2011 AIMSI were informed that there had been another maternal death in the Rotunda - in March 2011 - and the woman was once again non-national. The details AIMSI received were that she was a Polish woman, went in with pain and had an emergency section at 34 wks. The baby was rushed to NICU and she was later rushed to Mater, where she died. AIMSI were very concerned; if this report proved true, this would be the second maternal death of a non-national woman in a year.Attempts to verify this have been through the Rotunda and the Mater hospital, in which we were told they could neither deny nor verify.
April 28, 2011, AIMSI received further information - that a Polish woman had died 6 weeks previous in the Mater following a perimortum section in Rotunda. Cause of death pulmonary embolism.
 On April 28th,  supporters of justice for Bimbo discussed the issues and decided that a  Parliamentary Question (PQ) into the death of Bimbo Onanuga, an un-named Polish woman, and to find out why there was no HSE inquiry for these Rotunda deaths as compared with the response to the death of Monaghan woman in Our Lady of Lourdes.
Parliamentary Questions
On May 9, 2011, AIMSI wrote to TDs Caoimhghin O'Caolain and Clare Daly asking them to support and initiate a PQ on the issue of maternal deaths in Ireland, foreign national maternal death and maternity care, and why some maternal deaths are given full inquiries and others do not.

AIMSI wrote:

 AIMSI are writing to you asking you to support this PQ and to initiate a PQ on this issue in the Dáil through the People Before Profit party.

As you are aware, the HSE recently responded and apologised following an inquiry of a maternal death at Our Lady of Lourdes Drogheda - Tanya McCabe. The HSE have also recently responded to media reports of a second maternal death at Our Lady of Lourdes Drogheda, in which they have requested a full internal inquiry into the death.

AIMS Ireland wants to know why the HSE have not requested a full internal inquiry into the death of a foreign national woman at the Rotunda last year (March 2010). Her name was Bimbo Onanuga and the circumstances of her death are concerning. In fact, the only reason we know about it was that concerned Rotunda staff contacted AIMSI and a small local paper called the African Voice. It was not covered in the mainstream media. You can read more about Bimbo Onanuga's story here:

We are extremely concerned with the fact that this death is not having a proper inquiry. These concerns are further intensified by the fact that AIMSI have been contacted to report that a SECOND non-national woman, this time a Polish woman, has died in the Rotunda this past March 2011. Attempts to verify this story with the Master of the Rotunda and the Mater (where the woman was transported to die) have not been fruitful. We have been told that as we do not have the full name of this woman, they can neither confirm nor deny

On May 13, 2011, Clare Daly responded that she would ask a PQ on these issues.

On May 19th, Clare Daly contacted AIMSI with the following response:


DÁIL QUESTION addressed to the Minister for Health and Children (Dr. James Reilly )
by Deputy Clare Daly
for WRITTEN ANSWER on 19/05/2011  

 *  To ask the Minister for Health and Children the reason the Health Service Executive has not requested a full internal inquiry into the death of a person (details supplied) in 2010.

                                                                                          - Clare Daly

Details Supplied: Bimbo Onanugaw in the Rotunda Hospital in March 2010

When the case was received by HSE, it was assessed using the Investigation Procedure and Toolkit under the HSE established National Incident Management Protocol

The level of the investigation was decided by reference to the National Incident Protocol in light of the information on the case received  by HSE.  The case has therefore been investigated under that protocol by the HSE. Factors that contributed to this maternal death were identified in this review. To address these contributory factors and to prevent future harm arising from them 11 actions were recommended.

The hospital has indicated that 8 of the 11 recommendations have been implemented. Work on the outstanding 3 recommendations is in progress and due for completion shortly.


DÁIL QUESTION addressed to the Minister for Health and Children (Dr. James Reilly )
by Deputy Clare Daly
for WRITTEN ANSWER on 19/05/2011  

 *  To ask the Minister for Health and Children if a maternal death of a non-national woman occurred in a hospital (details supplied); and if an investigation is being carried out into the case.

                                                                                          - Clare Daly

Details Supplied: the Rotunda in March 2011

I am informed that a non-national patient who attended the Rotunda Hospital collapsed and was transferred to the Mater Hospital. She subsequently passed away in Intensive Care Unit in the Mater Hospital on March 8 of this year. A full adverse incident review by the HSE is currently in progress.

This PQ reply provoked more questions.

What are the 11 actions were which were implemented?
Why were the last 3 that haven't yet been implemented over a year later?
Can we see this report? Can it be requested through FOI?

On May 20, 2011, Clare Daly put in a THIRD PQ to request information on the recommendations from the Rotunda following the death of Bimbo Onanuga.

    DÁIL QUESTION addressed to the Minister for Health and Children (Dr. James Reilly )
    by Deputy Clare Daly
    for WRITTEN ANSWER on 26/05/2011  

     *  To ask the Minister for Health and Children if he will outline the 11 recommendations made in the investigation into the death of a person (details supplied) and the reason three of the recommendations have not yet been implemented over a year after the death.

                                                                                              - Clare Daly

    Details Supplied: Bimbo Onanuga in the Rotunda Hospital in March 2010

    This case was investigated under the National Incident Protocol by the HSE, using the Investigation Procedure and Toolkit to identify factors that contributed to this maternal death. To address these contributory factors and to prevent future harm arising from them 11 actions were recommended.
    Recommendations were made in relation to the need to identify clinical pathways for the management of such cases.

    The recommendations are as follows :
    1. The need to identify clinical pathways relating to management of women with an intrauterine death in third trimester to complement existing medical management policy.
    2. The Guidelines for Medical Management of Intrauterine Death should be revised in line with a review of the medical literature.
    3. Details of all patients for Induction of Labour, regardless of place of induction should be centrally documented.
    4. This recommendation cannot be disclosed as it contains personal, private, sensitive and confidential  information relating to the individual patient.
    5. Develop a brief operational outline of the Gynaecology Department to assist staff who are sent there on an occasional/intermittent basis.
    6. Due to the complexity of work, there is a need for an updated training needs analysis of all midwifery and nursing staff on the gynaecology ward.
    7. There should be a designated individual with responsibility for coordinating, monitoring and auditing the Basic Life Support attendance and Advanced     Life Support Skills attendance, ideally a designated Resuscitation Training Officer.
    8. An Obstetric Early Warning System should be introduced and evaluated.
    9. Install additional phone lines in the ward.
    10. A review of the possibility of emergency call bells or designated phones for emergencies in each room should be carried out and measures taken to address this.
    11. Hospital wide analysis of all doorways in clinical areas to establish the feasibility of moving a bed in a critical event. 

    The HSE confirm that all but the 7th recommendation have now been implemented.
    Discussions are underway in the HSE to bring the implementation of this recommendation to conclusion.

    It was now determined that the HSE did undergo an internal inquiry into the death of Bimbo Onanuga, but it had been done extremely quietly. It also appeared that recommendations following the inquiry were not to be published publicly. As this PQ reply did not address the issue of the report into the publication of Bimbo's death and so yet another PQ was initiated by Clare Daly.


    On May 27, 2011, the day after the Dáil reports of AIMSI PQs are published and it is reported in Irish, a HSE statement expressed it sincere sympathies to the family involved. However, the family were not contacted directly and are unaware of the statement.

    Fourth PQ

    June 3, 2011, AIMSI received the following reply.
    QUESTION NO:  137
      DÁIL QUESTION addressed to the Minister for Health and Children (Dr. James Reilly )
      by Deputy Clare Daly
      for WRITTEN ANSWER on 02/06/2011  

       *  To ask the Minister for Health and Children if he will publish the full report of the investigation into the death of a person (details supplied)..

                                                                                              - Clare Daly T.D.

      Details Supplied: Bimbo Onanuga at the Rotunda

      The question of publishing the report is a matter for the HSE. I understand that the full report cannot be released as it specifically relates to the patient care and personal circumstances of an individual whose rights must be respected. However, all of the recommendations of the report have been released other than one which relates to the individual patient. Details of these recommendations are included in my reply to you of 26th May 2011 in response to Parliamentary Question 109 .

      QUESTION NO:  106
        DÁIL QUESTION addressed to the Minister for Justice and Equality (Mr. Shatter)
        by Deputy Clare Daly
        for WRITTEN on Thursday, 2nd June, 2011.  

         *  To ask the Minister for Justice and Equality if he will implement procedures that require every maternal death, regardless of circumstance, should be submitted to a coroner's inquest.

                                                                    - Clare Daly

            The requirement to report a death to a coroner and whether to subsequently conduct an inquest is set out in sections 17 and 18 of the Coroners Act 1962. Under Coroners'  Rules of Practice, as outlined on the Coroners website, maternal deaths relating to childbirth are required to be reported to the coroner. The Coroners Bill 2007, confirms this by providing, inter-alia, in the Third Schedule on Deaths Reportable to Coroner, for the reporting of "any maternal death that occurs during or following pregnancy (up to a period of six weeks post-partum) or that might be related to pregnancy".  

            Fortunately, maternal deaths are exceptionally rare and this State has one of the lowest maternal mortality rates in the world. However, where such deaths occur, they are reported to a coroner and an autopsy would normally be held. It is then a matter for the coroner to decide, having regard to the circumstances of the maternal death, whether an inquest is necessary to determine the circumstances. There may be cases where an inquest would be unnecessary and leaving it to the discretion of the coroner is, therefore, considered to be the most appropriate public policy position.

          Investigations into Cytotec

          In early June, following PQs, some supporters of Bimbo began querying if she had been given cytotec to induce her labour. Cytotec has been shown to be linked with uterine rupture and death. Cytotec is a drug which was developed for the treatment of stomach ulcers and is not approved by the FDA for use in maternity purposes. Cytotec is used in maternity care to induce labour and manage excess bleeding following birth (PPH).

          June 5, 2011, Catherine Reilly writes an article looking further into the death of Bimbo Onanuga and the suspected use of cytotec.

          Inquiry Request

          June 2011 - Bimbo's partner, Abioloa,  writes to the Dublin Coroner's Office to request an inquest into Bimbo's death.

          November 2011 - Rotunda PR responses
          November 2011 saw several articles in which the Rotunda PR machine began commenting on the case from the view of overstretched maternity wards to blame for Bimbo's death
          And an interview with the Sunday Business post with Sam Coulter-Smith provoked the following letter to the editor:
          The Association for Improvements in the Maternity Services Ireland (AIMS Ireland) wish to highlight grave concerns re Maternal Death following your article (13.11.11), Dr Sam Coulter-Smith, master of the Rotunda Hospital. In the article, Mr. Coulter-Smith alludes to two maternal deaths of non nationals which occurred in the Rotunda Hospital over a 12 month period. Mr. Coulter-Smith states that investigations were undertaken and that the results were published.

          AIMSI wrote repeatedly to Dr. Sam Coulter Smith requesting information regarding the two incidences. At no point was any information made public. Furthermore neither death was reported in the national media. Neither death received a full HSE inquiry. Neither death received a public apology.

          Eventually, AIMSI were reduced to requesting THREE separate Parliamentary Questions to establish that the deaths had occurred and that there were recommendations associated with the multiple system failures following Bimbo Onanuga’s death and the unnamed East European at the Rotunda Hospital.

          By contrast, following a maternal death of an Irish woman in Our Lady of Lourdes, Drogheda during the same time period; a full HSE inquiry was immediately initiated, an apology to the family by the HSE was immediately given, and a full report of events appeared in all national media outlets

          Is the contrast due to poor management at the Rotunda, or due to the fact that the death of non National women in childbirth does not require the same accountability as the death of an Irish woman?
          Inquest Granted - Jan 2013
          In January of 2013 word was received that the Dublin City Coroner had granted an inquest into the death of Bimbo Onanuga. The inquest date was set for April 2013.

          April 2013 would see THREE inquests into maternal death in Ireland

          1. Jennifer Crean.
          2. Savita Hallapanavar.
          3. Bimbo Onanuga.
          At the Inquest - April 2013
          *At inquest, it was determined Bimbo had a uterine rupture due to induction
          *It was confirmed that cytotec was administered.
          *A 'serious doctoring' of notes was discussed
          * key witnesses were not present - those who cared for Bimbo on the day of her death
          *demands have been made that critical witness be subpoenaed - 'we need actual witness'
          The inquest was adjourned until July 5, 2013 with the hope to call 'critical' witnesses. '
          Critical witnessess' include doctor, HCP who witnessed death, a nurse, and Bimbo's partner.

          In July, the Inquest was adjourned to resume November 4/5th.

          Findings of Relevance for the Inquest for Bimbo Onanuga

          from the HIQA Report on the Death of Savita Halappanavar
          The HIQA report found:
          ‘A general lack of provision of basic, fundamental care, for example, not following up on blood tests as identified in the case of Savita Halappanavar’
          The HIQA report found:
          ‘The most basic means of identifying any patient at risk of clinical deterioration is to observe the patient’s general condition and regularly monitor and track their clinical observations. This should be a basic component of caring for any patient.’

          The HIQA report found:
          ‘Patients and members of the public are entitled to expect the highest level of healthcare. When the delivery of care falls below that level, they are entitled to ask why and be assured that measures have been taken to protect them and future patients from harm.’

          ‘It was also noted that there were many areas where maternity service needs were not being fully met at the time of the investigation. This finding reinforces the Authority’s concerns in relation to the inconsistency in the provision of maternity services in Ireland and the need to ensure that all pregnant women have appropriate access to the right level of care and support at any given time.’

          Key Questions about Bimbo Onanuga’s Care
            Did Bimbo Onanuga, who had a number of risk factors in relation to the intrauterine fetal death, receive the basic care, monitoring and a care plan consistent with her clinical needs?

          Was she appropriately and effectively monitored given the use of the drug misoprostol?

          Is the Rotunda prepared to fully divulge to the public the steps they have taken since Ms Onanuga’s death to reform care plans and retrain staff, in line with the international evidence on the use of misoprostol and to explain why their guidelines differ from those of the RCOG Greentop 55?
          ‘The RCOG is aware that protocols employing much larger doses of misoprostol are still being employed in the UK, with consequent potentially associated adverse effects. Each maternity unit is advised to review their protocol for the management of induction of labour under these circumstances and to adopt the recommended misoprostol dosaging.’ RCOG, 2010

          You can read more about Bimbo Onanuga's story

          Safety flaws highlighted in maternal death probe
          ‘They told me she was exaggerating - now she’s gone’ - Rotunda neglected care of Bimbo Onanuga says partner:,2747

          Maternal Death Inquiry - Bimbo Onanuga:




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