Mother’s Post Delivery Death Could Have Been Prevented

It has been reported in the news recently that the death of a pregnant woman on the maternity ward at a Derby hospital could have been avoided.

36-year-old, Rachael Chloe Walker, known as Chloe, sadly died at Royal Derby Hospital’s maternity unit on 19 June 2021.

Ms Walker had “recognised risk factors” and was diagnosed with placenta praevia, a condition in which the placenta either completely or partially blocks the neck of the uterus and can interfere with the baby’s delivery.

In the 34th week of her pregnancy, she was seen by the consultant obstetrician with lead responsibility for her care. A plan was made to review her at 37 weeks, with a c-section booked for week 38 due to the placenta praevia. This plan, however, was not written in the medical notes and so the obstetric registrar that saw her at 37 weeks was unaware of the plan.

Furthermore, the Trust had not adopted national guidance issued in September 2018 for consideration of delivery by caesarean section between weeks 36 and 37 for patients with Ms Walker’s condition.

On 19 June 2021, Ms Walker collapsed at home. She was taken to Royal Derby Hospital’s maternity unit. Her daughter was delivered successfully via emergency caesarean section but very sadly Ms Walker suffered three cardiac arrests as well as severe bleeding and died.

The coroner gave a cause of death as placental haemorrhage at 37 weeks of pregnancy, along with amniotic fluid embolism and placenta praevia.

The coroner concluded that, had a delivery plan been made for Ms Walker, recorded in her notes and acted upon, and if the Trust had incorporated the national guidance issued in September 2018 which provided for consideration for earlier caesarean delivery, it is probable her death would have been avoided.

The coroner also identified further “serious issues” relating to the Trust including no system in maternity to relay information from ambulance staff, no blood for urgent surgery kept in the unit, a delay in calling for the on-call consultant anaesthetist and “no robust system” in place for a major obstetric haemorrhage.

The coroner has issued several recommendations in order to avoid similar tragedies. These include a more “robust system” to be introduced for patients who suffer major obstetric haemorrhages and note handling should be improved to ensure all information is available.

Garry Marsh, executive chief nurse at the Trust said:

You can read our blog here regarding the HSIB review and report which found Ms Walker and two other women might have survived had the Trust implemented recommendations sooner.

Comment

It is heartbreaking to learn that Ms Walker’s death could have been prevented.

As expressed by the coroner, it is of particular concern that clinicians at the time were aware of the revised national pregnancy guidance issued in September, but that it had not been incorporated into the Trust’s policy and guidance.

The Trust’s maternity unit has faced significant scrutiny and pressure in recent years. It sadly appears the Trust still has a long way to go before confidence can be restored in their maternity unit.