RTÉ News has learned that an internal investigation by the National Maternity Hospital in Dublin into the death of a pregnant woman in May has found there was a delay in spotting a tear of a main artery caused during surgery and then in managing the problem and in resuscitation.

Malak Thawley was 34 years old, a teacher and a US citizen, who was expecting her first baby with her husband Alan when she died at Holles Street on 8 May.

The 239-page final report of the hospital investigation, seen by RTÉ News, has identified three critical causal factors during the emergency surgery.

Key Findings

There was an accidental tear of the aorta in the abdomen.

There was a lack of experience in recognising and managing a vascular injury, during laparoscopic surgery, due to the rarity of the injury.

There was sub-optimal communication between members of the medical team and as well as a delay in decision-making.

The delay in decision-making led to a delay in starting surgery and resuscitation.

Speaking about the case for the first time today Mr Thawley said his wife was a very beautiful person, physically and in her personality, and was loved by all.

Mr Thawley said he is still trying to understand how and why his wife died in the National Maternity Hospital.

Alan Thawley was speaking publicly for the first time about his wife's death

The couple had been living and working in Ireland for around three years.

He said they decided to have children when they arrived in Ireland because they loved the country so much.

Mr Thawley said he paid for a pregnancy scan at a private clinic in May as a surprise gift for his wife when she was seven weeks pregnant.

The scan revealed that she had an ectopic pregnancy and the couple were advised to go immediately to Holles Street Hospital given the news.

Ectopic pregnancies are rare and serious and are where the embryo implants somewhere other than in the uterus.

At Holles Street another scan confirmed the ectopic pregnancy and Ms Thawley was advised that she would require urgent surgery.

The report reveals that during the operation there was a vascular injury and Ms Thawley died in theatre.

The Coroner was notified of the case by the hospital.

The internal investigation was commissioned by Master of the National Maternity Hospital Dr Rhona Mahony.

This evening the National Maternity Hospital said the inquest is expected to begin soon and the facts of the case will be examined in public.

It said its thoughts are first-and-foremost with the family and friends of the deceased.

The hospital said it was unable to comment further and had released no detail on the issue to the media.

In the investigation report, the hospital said it is determined to ensure that the recommendations critically identified in the report will be implemented in a timely manner, to improve the systems and processes in place for laparoscopic procedures and emergency clinical situations.

One of the key recommendations is that Holles Street review training programmes to ensure the teaching of safe entry techniques, supported by a mentorship programme, for laporoscopy for doctors in training.