A mother who died from massive post-birth haemorrhage was ‘failed’ by NHS staff who gave her a biscuit thinking she was dehydrated, a report has discovered.
Laura-Jane Seaman, 36, died at Broomfield Hospital in Chelmsford, Essex, in December 2022, two days after the birth of her son.
The care support worker was ‘begging staff to help her’ and pleading that she didn’t want to die but medics from a ‘range of disciplines’ failed to listen.
This was despite her frantic warnings that she could feel the bleeding, felt lightheaded, and that her limbs had gone numb, as well as the fact that it was recognised she was at high risk of postpartum haemorrhage, or excessive postpartum bleeding.
Medical staff put Ms Seaman’s symptoms down to dehydration and after losing consciousness she was simply given a ginger biscuit for her to eat.
Ms Seaman ended up suffering two cardiac arrests when her condition worsened and was taken into emergency surgery, but tragically passed away on December 23.
Prevention of Future Deaths report has since discovered there were ‘multiple missed opportunities to escalate and treat’ Ms Seaman in the lead-up to her demise.
Coroner Sonia Hayes said the mother-of-five’s ‘maternal collapse’ was classified as a faint and she was treated for possible dehydration and given medication that had ‘only a transient effect’.
Ms Seaman had a normal vaginal delivery on December 21, 2022. She breastfed her son and there were plans to send her home before her condition started to decline.
It was later established the internal bleeding had gone on for hours before she had emergency surgery and was admitted to intensive care, where she died.
The report said that Ms Seaman ‘died as a consequence of basic failures by healthcare professionals to recognise and escalate her loss of consciousness as a maternal collapse’.
It added that staff’s ‘inability to obtain vital signs’ was ‘incorrectly attributed to malfunctioning equipment rather than obvious clinical deterioration’ had they utilised the correct procedures.
‘Laura-Jane suffered a splenic capsular tear on the labour ward that caused an intraperitoneal bleed that continued undetected in the absence of any examination of her abdomen,’ the report said.
It said that ‘vital signs that were obtained were severely deranged’ for a period of two and a half hours, adding that ‘the consequential risk to her life that was obvious’.
Coroner Hayes wrote that had action been taken ‘with multi-disciplinary consultant-led review’ this would have resulted in care and treatment that would have saved Ms Seaman’s life.
The report concluded that her ‘death was avoidable and was contributed to by neglect’.
In her ruling earlier this year, Ms Hayes said healthcare professionals were responsible for multiple ‘gross failures’ over Ms Seaman’s death and would not have died if these had not occurred.
Notes on Ms. Seaman’s health were marked on paper, which prevented concerns from being escalated quickly, and hindered her treatment.
Concluding the inquest in August, Ms Hayes found there was a failure to trigger a major haemorrhage protocol and a lack of intervention by a multi-disciplinary consultant.
Staff’s inability to obtain vital signs after Ms Seaman fell unconscious ‘was incorrectly attributed to malfunctioning equipment’.
The coroner added there should have been a mandatory escalation before Ms Seaman died and warned she would be writing a prevention of future deaths report.
Suzanne White, head of clinical negligence at law firm Leigh Day, who represented the family, said: ‘She had a high-risk pregnancy, which should have been consultant-led, and observations were not appropriately undertaken which would have indicated how quickly Laura-Jane was deteriorating.
‘The coroner’s experts made it clear whilst giving evidence that Laura-Jane would have survived had the most basic level of care been given to her.’
Maternity services at the hospital were rated as ‘requires improvement’ in the most recent Care Quality Commission inspection.
A spokesman for Mid and South Essex NHS Foundation Trust said: ‘Our focus has been on improving training in recognising the early signs of deterioration and escalation routes in our maternity services to prevent this from happening again.’
This was an awful and unnecessary tragedy. It really makes you terrified of falling unwell and having to put yourself at the mercy of the NHS and in recent years they don’t appear to care or listen.
Has anyone been prosecuted for this crime because it is a crime? They failed their duty of care. Hospitals are very frightening these days – you go in, but you don’t come out.
Did they not think to locate other equipment to utilise after determining that the equipment was defective? It appears that hospitals, which are meant to be the safest places to give birth, are unable to recognise a woman who is dying.
A watch with a second hand, a stethoscope and a mercury sphygmomanometer is all that was needed. They’ve been in existence for over 100 years, but no doubt the staff relied upon a new-fangled electric machine because it takes far too much time and effort to do it the old-fashioned way.
And why would you give a patient a ginger biscuit for dehydration? Water perhaps!
This was a wrongful death and they should face professional and criminal charges.
Remember when you clapped during COVID-19 for medics like this? Not clapping now, are you?
After spending billions, the NHS has still failed to fulfil its responsibility of care, which is disgusting.
A spokesman for Mid and South Essex NHS Foundation Trust said, ‘Our focus has been on improving training in recognising the early signs of deterioration and escalation routes in our maternity service to prevent this from happening again.’
This is fundamental medicine. Recognising when a patient is deteriorating and going into hypovolemic shock is one of the first things medical professionals learn. I am pretty sure that what happened here was a basic failure to adequately complete a history and physical examination, and a failure to do the basics like check the pulse and manually measure the blood pressure.
Those who failed this woman should be struck off whatever register they are on.
THE MONTHLY MOSQUITO 