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Mother died after post-birth treatment delay at Gloucestershire Royal Hospital


A father whose wife died after childbirth believes she would still be alive if she had given birth elsewhere.

Rana Abdelkarim died at Gloucestershire Royal Hospital in March 2021 after suffering a bleed post-birth. The hospital has since apologised.

Modar Mohammednour, who made a home in Gloucestershire after leaving Sudan while being able to speak little English, said that in March 2021, his wife attended the maternity unit at 39 weeks into her pregnancy for what she thought was a routine check-up.

Mr Mohammednour, 44, said that, due to language barriers, his wife thought she was going "for a scan and to check on her health" and then return home but she was being sent for her baby to be induced.

"Immediately" after the labour, Ms Abdelkarim suffered heavy bleeding and her condition deteriorated, something Mr Mohammednour said he was "unaware of" until he was eventually called into the hospital to speak to a doctor.

Mr Mohammednour said: "He [the doctor] just came back and said to me: 'I did the best to save her life, but I couldn't'. I was feeling - 'I am dreaming'. She was talking to me yesterday. She was so in good health, what happened to my wife?"

An investigation into her death by the The Healthcare Safety Investigation Branch (HSIB) found there were delays in calling for specialist help, and the obstetric team of senior doctors was not told about the drastic change in her condition for almost 30 minutes.

The HSIB also found that once Ms Abdelkarim had been given a drip to speed up labour, regular support from midwives and assessments could not be given to her because the maternity ward was so busy. It also discovered there was a 53-minute delay from the point of bleeding to administering the first blood transfusion.

The HSIB also found Ms Abdelkarim was "uninformed" about the reason for her admission, "consent to induce labour was not given" and because she was thin and small, staff underestimated how much relative blood volume she was losing.

The HSIB said: "There was no effective communication with Rana and the events that occurred traumatised staff."

Mr Mohammednour, who is now bringing up his two daughters alone, said six-year-old Reem asks him "all the time about her mum." He added: "My excuse is just to say to her 'she is in paradise'."

Interpretation problems and the handling of heavy bleeds were highlighted in a report by health and care regulator, the Care Quality Commission, (CQC) following an unannounced inspection of the Gloucestershire Royal NHS Foundation Trust in April 2022. It found a high number of serious safety incidents involving mothers and babies.

The report also said staff could not always identify when a woman's condition was deteriorating with women, including Laura Bowtell, losing her baby Margot after staff failed to identify she should have given birth in a consultant-led unit.

The hospital said it had implemented all 10 recommendations made in the HSIB report.

The trust’s deputy chief executive, Professor Mark Pietroni, said a review was carried out after the MBBRACE-UK report and the trust had "identified key themes for learning and intervention.

He said the data for 2021 "shows a marked reduction in stillbirths and neonatal deaths" and the hospital was "absolutely committed to delivering the safest possible service."

He added that the service continues to make improvements "in the interest of patient and staff safety" after the CQC inspection, including one-to-one care in labour.

He added: "Tragedies such as these are thankfully rare and it is important to stress that our maternity outcomes are in line with comparable maternity units, nationally."

He said it was "vital" for the hospital to "take every opportunity to understand the factors that might have contributed to such a tragic outcome" and to "learn and make care as safe as possible."

The latest published maternity safety data from MBRRACE-UK showed in 2020, the year before Ms Abdelkarim died, Gloucestershire was one of just six trusts in the country that had two "red flag" warnings for having stillbirth and newborn death rates more than five per cent above the average for similar units.

In one case that year, baby Freddie Whewell had his skull fractured in delivery and his brain was starved of oxygen. An inquest found his mother, Jay Whewell, was third in the queue for an emergency caesarean and Freddie might have lived had he been delivered sooner.

MBRRACE Lead, Professor Elizabeth Draper, said while being identified as red "wouldn't necessarily identify them specifically as a unit that has a particular problem", it is "really important" for those units identified as red to "look at all" the "cases of still birth and neonatal mortality" and "review the care provided for those cases.