Medical negligence behind 'C' section death at Essex maternity unit
An inquest has heard that a delay in an emergency Caesarean section caused a death
at a maternity unit that has been called one of Britain's worst.
Walthamstow Coroner's Court heard that although Violet Stephens gave birth to a boy at Queen's Hospital in Romford, Essex, the 35-year-old's condition rapidly deteriorated and she died soon afterwards.
Ms Stephens, who was 8 months pregnant, would have had more chances of survival had she received the 'C' section 1 day earlier
, the inquest heard.
Although the Caesarean was eventually performed, unit staff failed to administer an urgent blood transfusion
when the patient's blood pressure rose and Ms Stephens died.
The inquest was told of a history of medical negligence at Queen's, whose delivery ward has been called "the worst in Britain". In 2010 the unit had 3 maternal deaths, reflecting a mortality rate of 3 times the national average for maternity wards.
Ms Stephens had been diagnosed with pre-eclampsia and had developed HELLP syndrome
, a life-threatening condition which causes progressive nausea and vomiting, upper abdominal pain and headaches.
HELLP can also lead to fatal liver problems. Although fewer than 1% of pregnancies are affected, HELLP is found in 10 to 20% of cases with severe pre-eclampsia.
Prof Susan Bewley, a senior obstetrician who oversaw an external review of the incident at Queen's, observed that opportunities to plan ahead for the delivery of the baby on 8 April had been missed.
"There was no reason to delay and every reason to act quickly
," said Prof Bewley, adding that the failure to give Ms Stephens an urgent blood transfusion could have contributed "materially" to her death. Prof Bewley also blamed poor communication during handovers.
The inquest also heard that a consultant, failed to provide her colleague with important details such as the patient's name, date-of-birth and hospital number, merely referring to Ms Stephens as "the 31-weeker in the antenatal unit". The court heard that these failings resulted in significant delays in identifying Ms Stephens and obtaining her blood tests.
Recording a narrative verdict, the coroner for east London Chinyere Inyama said: "On April 8, a serious failure between consultants to properly hand over the care of the deceased led to a missed opportunity to plan the premature delivery earlier."
"An earlier delivery could have affected the outcome. Post-delivery, there was a failure to give the deceased an urgent blood transfusion in a timely fashion."
"It is likely that this failure materially contributed to the outcome."Useful links