Probe found “failures” after mum’s death in Romford maternity
PUBLISHED: 16:32 29 September 2011 | UPDATED: 16:39 29 September 2011
Violet Stephens was a proud mother-of-two and was looking forward to the birth of her third child, a baby boy.
But the 35-year-old died in Queen’s Hospital’s maternity department - soon after the traumatic birth of the infant.
A report by independent investigators, seen by the Recorder, describes a “succession of failures” into her care at the Romford hospital, in Rom Valley Way.
Violet, who lived in Brentwood, had a history of difficult births, with two previous emergency caesareans sections (CS) due to high blood pressure, the report said.
When she was admitted in April, she was found to have pre-eclampsia (PET) - a major cause of death in pregnant women.
But she wasn’t transferred quickly enough to the labour ward, the report said, and she “did not receive the standard of care she was entitled to.”
After the birth, Violet became seriously ill, but a planned blood transfusion did not take place quickly enough and the “severity and rapid deterioration of [her] condition was not recognised or managed in a coordinated way.”
She died of liver problems, three days after she was admitted. She had seen more than 30 health staff in that time, but the report said “the number and extent of service provision weaknesses revealed by this investigation casts doubt on the organisational integrity of the maternity services.” Her baby survived.
However, investigators did find much evidence of “good care, kind staff, close observations, up-to-date relevant guidelines, clear documentation and effective communication”, at the unit - one of the biggest in the country and with a maternity death rate below the London average.
The Care Quality Commission is currently investigating care at the department. The findings will be published next month.
Sarah Harman, of Harman and Harman Solicitors, has lodged a litigation claim on behalf of Violet’s family against Barking, Havering and Redbridge Hospitals Trust, which runs Queen’s maternity department.
She said: “There was failure by staff to communicate properly, there were too many staff dealing with one sick patient; and not enough liaison. I believe, on behalf of the family, that had proper care been available, Violet would have survived. Now three children are without their mother.”
Sarah has lodged another 11 claims by women or their families over care at Queen’s.
It includes the family of first-time mum Serena Ali, known died of a heart attack in January caused by a ruptured womb. The trust admitted failings.
Averil Dongworth, the Trust’s chief executive, said: “I was very concerned to hear we had failed to give this seriously ill woman the high standards of care she should have been able to expect and would like to apologise on behalf of the Trust.
“I’m determined these issues are addressed so every woman can be confident about our maternity service.
“Our senior doctors, midwives and other maternity staff gathered together in a special conference to learn the lessons from this case.
“We have improved medical input into women being cared for on our antenatal care unit, ensuring a consultant obstetrician sees each inpatient every day.
“We have put in place new guidelines to safeguard women who have their labour induced or have complications.
“We have ensured we have one of the highest levels of specialist doctor coverage of any maternity unit in the country.
“Our midwife staffing levels have increased so every woman can have one-to-one care while in labour.
“These changes are part of a rigorous action plan to improve our maternity service and make sure every woman can have a good experience of childbirth in the safest possible environment.”
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