Clinical Negligence & Catastrophic Injury Solicitors
Twins' mum died after giving birth.
Estelle O'Sullivan lost three litres of blood following the caesarian operation to deliver her twins and died from a cardiac arrest soon after.
A coroner heard that an emergency button in the operating theatre did not work, leaving a midwife to dash through hospital corridors to get help when things went wrong.
Medics at Wexham Park Hospital in Slough, Berkshire, had also written down the wrong type of blood on the patient's records, specialist fluids ordered to be delivered to the hospital were given to the wrong patient and essential operating instruments were missing from the theatre, the inquest heard.
Berkshire Coroner Peter Bedford was told that Ms O'Sullivan had a previous child who was born by caesarian section.
Because of a blood disorder and a pregnancy problem she suffered, it was decided she should be declared "high risk" and have the same operation for the birth of the twins.
Ms O’Sullivan, 37, had a condition which meant her blood did not clot properly and she had been admitted to hospital throughout her pregnancy with heart palpitations and dizziness.
But the day before her death, her waters broke and she was admitted to the maternity ward.
Ms O'Sullivan, of Slough, Berkshire, had lost half a litre of blood by 11am on the day of her death at Wexham Park Hospital but reported feeling well and feeling her twin boys moving inside her.
However, hours later she began to feel severe pains in her stomach and, by the time that the babies' heart rates were hard to monitor, the situation was escalated to an emergency.
An ultrasound examination was carried out, raising alarm over the health of the babies.
The twins were born just before 3pm on February 26 2016 and were rushed to the Special Care Baby Unit but their mother suffered a cardiac arrest on the operating table.
When a midwife pressed the emergency call button, it did not work and she had to run to the labour unit to call for help, the coroner was told.
Midwife Tiffany Gurbishley told the inquest that 775ml of blood had been lost during a 24-hour period when Ms O'Sullivan reached the operating theatre.
She said: “Estelle was taken to the operating theatre with an estimated blood loss of 775ml and put in the care of a consultant. I scrubbed up to receive twin two and I remained in the theatre until both babies were in the Special Care Baby Unit.
"The anaesthetist made us aware that Estelle had a cardiac arrest and I ran to the labour unit as the bell had failed. The purpose of the emergency buzzer is to get extra hands there. The consultant, Mr Wagley, carried out CPR."
Ms O'Sullivan was treated as a high-risk patient as she was carrying twins and had had a C-section before. She was also treated as high risk because her waters had broken pre-labour making both her and the babies vulnerable to infection, the inquest heard.
Consultant anaesthetist, Dr Suraj Jayasundera said plans had been put in place for the operation to be carried out on Thursday, February 26, as an 'elective' C-section but a search was made for an earlier time slot.
"At 6pm I spoke to transfusion," he said. "They had no platelets but could send them by blue light from Oxford. Platelets help blood clot. They are needed to be in significant numbers to help blood clot."
Coroner Mr Bedford said: "There is a reference here to the possibility Estelle received the wrong blood."
Dr Jayasundera said he did not know about a mix-up in blood types and a scan for placenta accreta, a life-threatening condition where the placenta attaches to the uterine wall, revealed Ms O'Sullivan "was not known to have the condition".
He told the coroner's court: "A number of scans were done and she was known to be a high-risk patient.
"I explained to Estelle that if she bled again she might have to be given general anaesthetic and be moved. More than one bag of platelets was needed. We agreed to try to get it done the next day. I think they were a bit concerned about an emergency happening at the same time."
Due to foetal distress, a Category One - the most urgent - C-section was carried out and the babies were delivered just before 4pm.
An hour later, Ms O'Sullivan suffered a cardiac arrest.
But, apart from the emergency call button not working, a defibrillator was found to be low on battery, it was discovered there were no platelets at the hospital and that the units of blood were low, although nine units were eventually transfused.
Dr Ndubueze Anyaegbuna treated Ms O'Sullivan on the day of her death and stayed with her in the Intensive Care Unit where a decision was made to stop resuscitating her.
Mr Bedford said: "The suggestion in the report is that morbidly adherent placenta was recognised but not documented. Was the significant blood loss underestimated?"
Dr Anyaegbuna told him: "I don't think the severe blood loss was underestimated. You have to cut the anterior placenta to deliver the baby. She had lost nearly a litre of blood."
Mr Bedford said a report revealed the volume of haemorrhage was underestimated at the time the cardiac arrest and meant staff did not adequately respond with blood products.
However, the consultant told him the presence of pulmonary oedema - fluid in the lungs - suggested this was not the case.
He said Ms O'Sullivan haemorrhaged quickly and staff tried to understand what could have caused the cardiac arrest, including considering septicaemia or anaphylactic shock.
He said prior to the cardiac arrest everything was going as it should have done.
The coroner said estimated blood loss in the haemorrhage was three litres but that a report criticised communication between staff about the blood loss before and after the operation, making the severity of the situation unclear.
Abdul Wagley, a consultant who saw Estelle in the days before her death, faced questions about a faulty defibrillator, delays in carrying out a blood transfusion and the possibility that she had been given blood incompatible with her blood group, as well as why blood platelets assigned for her were given to another patient.
The inquest was told that the cause of death was cardiac arrest caused by postpartum haemorrhage, caused by placenta praevia.
Mr Wagley said: "It was a sudden, massive blood loss which went on for about 15 minutes and thereafter there was slower blood loss but more controlled."
Mr Wagley, who said he had carried out 90 C-sections at the hospital between 2011 and 2015 and around 1,000 in his career, explained that there were two protocols in place at the operating theatre and the one for massive blood transfusions would mean blood products were brought at regular intervals to the surgeon and a call would need to be placed to end it.
Mr Bedford recorded a conclusion of death by natural causes but went on to say there was a gross failure to provide her with basic medical attention.
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