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Coroner slams hospital's incompetence as mother-to-be is third in family to die of same condition |
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27 March 2008 |
A Hampshire woman was the third in her family to die during childbirth at the same age of 22, from the same rare condition, an inquest has been told. Hospital staff failed time after time to take her rare condition into consideration, and the coroner has described the hospital's behaviour as 'like going through six or seven red lights and not realising'.
A Hampshire woman was the third in her family to die during childbirth at the same age of 22, from the same rare condition, an inquest has been told. Hospital staff failed time after time to take her rare condition into consideration, and the coroner has described the hospital's behaviour as 'like going through six or seven red lights and not realising'.
Kelly Hutchings of Fareham died at Southampton general hospital from a brain haemorrhage caused by deep cerebral venous thrombosis. An error in hospital administration meant that she did not see a consultant until she was gravely ill, despite her family history, the hearing was told.
Keith Wiseman, the Southampton coroner, said he found it 'incredible' that her case had 'slipped through the net'. Miss Hutchings' mother, Shirley, and her aunt, Sue Hickmott, had both fallen victim to the same type of brain haemorrhage in the 1980s. All three women were 22 and pregnant when they died.
Miss Hutchings became pregnant in the spring of 2005. However, despite referrals by her doctor and a midwife for her to see a consultant obstetrician to oversee her pregnancy, no appointment was made. The need for her to receive specialist care was overlooked by midwives and doctors on up to six further occasions, the inquest heard.
A clerical error meant that an appointment for her to be seen by a consultant obstetrician never happened, another appointment was downgraded to one with a midwife, while a number of further opportunities for Miss Hutchings to be referred were overlooked.
She was eventually admitted to Southampton General Hospital's neurological unit for tests when she started to suffer from dizziness and headaches. Her condition deteriorated and, at 30 weeks pregnant, she went into labour.
She gave birth by caesarean section to a daughter, Nikita, who was born with severe disabilities and weighing 3lbs 6oz. Miss Hutchings died during the birth on Nov 16, 2005. The child is being looked after Miss Hutchings's partner, Lee Blyth.
Donna Ockenden, the head of midwifery at Portsmouth Hospitals NHS Trust, told the inquest: 'It would appear that although the history was clearly visible on the front of Kelly's notes, it was not picked up that it was a high risk issue. At any time a re-referral could have been made simply by picking up the phone and it appears that did not happen.'
Mr Salloum, of St Mary's Hospital, Portsmouth, said: 'Kelly was anxious that her mother and her aunt both died in childbirth from a brain haemorrhage. I considered her case to be high risk and ticked a box for her to be seen by a consultant. It may not have made any difference in this case, but it would have let us look at the possibilities.'
But Sandra Patton of Kester Cunningham John suggests that such oversights are all too common in obstetric cases.
'Ticking boxes is I'm afraid what it comes down to,' she says. 'Far too often the NHS operates at the lowest common denominator of bureaucratic bungling.
'At a time when the government is apparently keen to make the NHS more patient-focused, we're still dealing with deaths and injuries caused by patients still being seen as passive participants in a bureaucratic process. A name at the top of a form, some boxes ticked. A hurried doctor or nurse with a queue of other patients is reduced to seeing the patient as just that - a name on a form.
'A ticked box hardly registers as a priority in those circumstances, even though as in this case the ticked box meant the difference between life and death. That is the only explanation for the incredible incompetence illustrated here.
'Expectant mothers in particular are extremely vulnerable when they go into hospital for delivery and can be intimidated by the apparently huge and professional operation going on around them. Yet in reality they are often just part of a process, and a process which has sometimes lost its direction and forgotten that the patient is the whole reason everybody is there.'
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