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Young mother's treatment delay contributed to her death after 'catastrophic' labour, coroner rules


A coroner said a ‘delay’ in treatment of a teenager who died following a ‘catastrophic’ labour contributed to her death.

Teegan Barnard, 17, suffered a cardiac arrest two hours after her healthy baby boy, Parker, was born at St Richard’s Hospital, Chichester on September 9, 2019.

The ‘small’ teenager from Havant suffered a ‘major’ bleed giving birth to Parker, who weighed 9lb 9oz, losing almost four litres of blood. As a result of the bleed, Teegan was starved of oxygen and suffered a severe brain injury. She later died at her home on October 7, 2019.

At an inquest at West Sussex Coroner’s Court, assistant coroner for south east England, Dr Karen Henderson, said the ‘prolonged’ inquest process had been ‘challenging’ and had made a ‘significant impact’ on all involved.

The inquest heard different professional opinions about the cause of Teegan Barnard’s cardiac arrest.

A consultant anaesthetist who treated Teegan, Dr Philip McGlone, had said it happened as a result of bronchospasm, when airways in lungs tighten. Another doctor thought she could have suffered an adverse reaction to drug Carboprost, a medication given in childbirth emergencies to stop Postpartum haemorrhaging while another expert thought Teegan was suffering with bilateral tension pneumothoracies, a severe condition in which air is trapped in the chest and puts pressure on the heart.

Amid opposing views, the coroner had previously called for expert witnesses to help determine if medical intervention could have made a difference before adjourning the inquest, but the expert witnesses had disagreed about whether a potentially life-saving measure should have been undertaken sooner.

However, Dr Henderson said a ‘catastrophic inability to ventilate’ was crucial after she ‘accepted the evidence’ of a consultant thoracic surgeon at University Hospitals Birmingham, Mr Ehab Bishay.

Mr Ehab Bishay said the teenager was not responding to ventilation and began to suffer air ‘ballooning’ across her body, leaving her arms so swollen her medical name band had to be cut from her wrist. He said: “If you haven’t seen surgical emphysema, you might think anaphylaxis.”

Teegan’s medical team undertook abdomen incisions to release trapped air, believing this was primarily located in the space between her lungs. These incisions were followed by two more between the teenager’s ribs in another attempt to relieve pressure on the lungs, a procedure that should have been undertaken sooner, according to Mr Bishay.

The consultant said: “In my opinion the bilateral thoracotomies should have been undertaken sooner. Every minute counts. Had they been done sooner then the hypoxic brain injury would have been less likely. If you look at the post-mortem, it’s clear the hypoxic brain injury was the real cause of death. It’s my opinion she wouldn’t have died had they been performed sooner.”

The coroner, despite admitting bilateral tension pneumothoracies was a ‘rare complication’ and acknowledging the benefit of hindsight, said it should have been ‘considered and excluded at an early stage’ especially with there no evidence of anaphylaxis bronchospasms.

Giving her conclusion, Dr Henderson, said: “Teegan had sustained an irrecoverable hypoxic brain injury following a prolonged cardiac arrest on emergence from a general anaesthetic after an emergency at St Richards Hospital Chichester.

“The cause of the cardiac arrest was due to bilateral tension pneumothoracies the cause of which remains unclear but in circumstances whereby a delay in the recognition and treatment thereof made a material contribution to her death.”

The coroner confirmed she would be writing a report to prevent future deaths after stating she was ‘concerned and wished to be reassured the death was not a systemic issue.’

After the hearing Teegan’s mother Abbie Hallawell said in a statement: “The last three years have been a living nightmare which no parent should have to go through. Our lives are not the same without Teegan. She was such a loving and caring girl who enjoyed meeting friends and horse riding. She had an infectious personality and a wonderful smile. It’s devastating to think she’ll never get to fulfil her potential in life.

“We’d like to thank the coroner for carrying out such a thorough investigation and listening to our concerns. While the inquest and listening to the evidence as to why Teegan died has been incredibly traumatic it’s something we needed to do to honour her memory.”

Medical director and chief of service for Women and Children at University Hospitals Sussex, Dr Tim Taylor, said: “We wish to extend our sincere condolences to Teegan’s family for their terrible loss. Her death was an extremely rare tragedy that we know has deeply affected everyone involved.

“We are determined that all possible learning from the inquest will be acted upon as we continue do all we can to improve our services for women and children in our care.”