Mother died after waiting THREE DAYS for emergency Caesarean at ‘worst maternity unit in Britain’

By
Eddie Wrenn

Last updated at 3:33 PM on 17th February 2012


Violet Stephens: Died hours after giving birth in an overcrowded ward

Violet Stephens: Died hours after giving birth in an overcrowded ward

A mother died after waiting three days for an emergency Caesarean section because of failings at one of the country’s worst maternity units, an inquest heard.

Violet Stephens, 35, was just eight months’ pregnant and had a history of problems during previous births at Queen’s Hospital in Romford, Essex.

Her chances of survival would have been better if she had been given the Caesarean section a day earlier, the inquest heard.

When
Ms Stephens finally had the operation, a failure to give her an urgent
blood transfusion had a material effect on her death.

Walthamstow Coroner’s Court was told staff at the unit failed to react promptly when Ms Stephens’ blood pressure soared.

She gave birth to a boy, Christian, her third son under five, at 31 weeks, but her condition deteriorated rapidly and she died shortly afterwards.

In 2010 the hospital had three maternal deaths which, gives it a death rate three times higher than the national average for maternity units.

The delivery ward at Queens Hospital has been dubbed ‘the worst in Britain’.

Ms Stephens’ had been diagnosed with pre-eclampsia and developed HELLP syndrome, a life-threatening complication which can lead to fatal liver problems.

HELLP occurs in less than one per cent of all pregnancies, but in 10 to 20 per cent of cases with severe pre-eclampsia.

It can cause progressive nausea and vomiting, upper abdominal pain, headaches and vision problems.

The hospital is facing legal action by 12 women and their families over care they received at the hospital’s maternity unit.

Senior obstetrician, Professor Susan Bewley, who produced an external review of events that led to Ms Stephens’ death, said: ‘There were a number of missed opportunities to plan ahead for the delivery of the baby on April 8.

‘There was no reason to delay and every reason to act quickly.’

Professor Bewley said that the failure to give Ms Stephens an urgent blood transfusion could have ‘materially’ contributed to her death.

She added that poor communication during handovers was also to blame.

The inquest heard that Dr Farida Bano, consultant obstetrician and gynaecologist failed to given colleague Celia Burrell crucial details including Ms Stephens’ name, date of birth and hospital number, simply referring to her as ‘the 31-weeker in the antenatal unit’.

As a result, there were significant delays in identifying Ms Stephens and obtaining her blood tests, the court heard.

Queens Hospital, Romford, was criticised following Mrs Stephens' death

Queens Hospital, Romford, was criticised following Mrs Stephens’ death

The Caesarean did not take place until after 4am on April 9.

The ward was at ‘fever pitch’ and that staff could have been too stretched to cope, the inquest heard.

Midwife Debbie Graham, who co-authored the independent report, added: ‘If you really are at full capacity perhaps you should think about closing the unit – if another woman arrived who was ill, you would be making a bad situation worse.’

Ms Stephens’ sister, Kitty Mhango, a nurse and midwife, told the inquest: ‘I felt she was not looked after properly.

‘This was her fourth pregnancy at the same hospital and they had records which showed she was a patient with issues before.

‘I thought they didn’t take action early enough, that’s why, when I heard she had died, I was so angry, I felt they had let her down.’

Mr Bano insisted she had passed on the patient’s name, but not the date of birth.

Recording a narrative verdict, Chinyere Inyama, coroner for east London, said: ‘On April 8, a serious failure between consultants to properly handover the care of the deceased led to a missed opportunity to plan the premature delivery earlier.

‘An earlier delivery could have affected the outcome.

‘Post-delivery, there was a failure to give the deceased an urgent blood transfusion in a timely fashion.

‘It is likely that this failure materially contributed to the outcome.’

Speaking outside the court, Ms Mhango said: ‘My family and I can finally put the matter to rest with the assurance that no one else will go through what my sister went through.

‘I hope the hospital in future will be able to identify strategies to improve nursing and medical response for acutely unwell and deteriorating patients.

‘We are trying to cope but it’s very difficult.

‘Violet was so lovely, she laughed a lot and she loved her children, she loved going to the park with them and they will miss that.

‘Christian is okay, he is a lovely boy and he is growing.

‘We will reassure Violet’s sons that she was a loving mother.’

HOSPITAL APOLOGY

Chief executive of the Barking,
Havering and Redbridge NHS Trust, Averil Dongworth, said in a statement:

‘The trust fully accepts the inquest verdict and I would once again like
to apologise to Ms Stephens’ family for their loss.

‘We are determined that lessons are learned from Ms Stephens’ death.

‘We have made extensive changes to our maternity services over the last year.

‘We
have increased consultant cover out of hours and have the highest level
of consultant obstetrician cover in a labour ward in London.

‘We
are working with trusts across the capital to manage capacity so that
women can be given dedicated one-to-one care in our hospitals.

‘We have also hired more than 100 new midwives, extra consultants and have retrained staff.

‘Systems
have been improved and new ways of working introduced, to ensure that
women receive the safe, high quality care they deserve.’

Here’s what other readers have said. Why not add your thoughts,
or debate this issue live on our message boards.

The comments below have been moderated in advance.

I’m sick of commenting on the bad maternity care offered by Queens Hospital which is where I had my daughter in 2009. Why do these awful stories keep happening, FIX IT!

Lessons to be learned ONLY AFTER SOMEONE DIES, I would suggest that those in charge try to learn something before hand.

So yet again, “everyone” seems to “know” that the service offered by this unit is substandard and apparently failing in many areas of care, but yet nobody seems to have done anything. Wake up the local MP? Petition the Health Minister? Get the failing hospital bureaucrats removed from office? All these people are accountable to US because WE pay their salaries.

And the Chief Executive and senior managers get paid how much? For what?

I had my son here in 2008 and although I had no issue with my care, other than being induced early evening and my partner being sent home meaning I did most of my labour in a ward with other women all night alone, I saw some pretty shocking and horrendous treatment someone else. A lady was having her fourth baby and had been induced like me. Her labour obviously progressed very quickly and despite asking for pain relief many time was not given any then she was teased with it by the midwife telling her to ask for it properly. The poor woman couldnt even speak due to the pain she was in by this time. She had vomitted and wet herself, she was asking for help to get to the toliet and the midwifes wouldnt take her. By the time her husband was called to return at 6am she was almost fully dialated. He questioned why she had been left in this state, in pain and covered in vomit and urine and the midwife said that she had tried to help her but the woman refused. A blatent lie.

We have maternity ward experience at that ghastly hospital. To the midwife that said that they are short-staffed, that may be the case, but you are rude and unsympathetic to people who are vulnerable. If I hadn’t have forced the ignorant midwife to get a doctor (on threat of being ejected), our son would have died in childbirth and would had been another statistic.
I’d like to see some heads roll at the top. That’s the ONLY way difference is made.

The three way mantra of NHS management -Lessons will be learned. We are working hard with our stakeholders. Give me my bonus!

My heart goes out to the family. How absolutely awful. Since this happened I know that Queens hospital have made a lot of improvements following the CQC report including increased staffing, a capping system, moving elective c-sections to another hospital and sharing the patients more consistently with Basildon and Chelmsford hospitals. I had my twins by emergency c-section following a 30 hour induction on the antenatal and labour wards, just over 11 weeks ago and I cannot fault any department or member of staff – they were fantastic. You may say that I was just lucky but the optimist in me would hope that this is a sign that serious improvements have been made over the last two years. Whilst it will never bring back those who have passed away it will hopefully ensure the safe births for future mothers. Certainly shutting the unit and putting pressure on every other local hospital is definitely not the answer and will just shift the problem elsewhere.

Chief executive of the Barking, Havering and Redbridge NHS Trust, Averil Dongworth, said in a statement: We are determined that lessons are learned from Ms Stephens’ death.
After 65 years of the NHS, what lessons are there to be learnt.? Everyone knows that when we hear this comment it means poor management of staff and procedures. Sloppy practices have been allowed to develope but no one will be held accountable.
As my father used to say, hospitals bury their mistakes.

– Andjelija, London, 17/2/2012 11:19 Your ramblings and mutterings about what you got for 10 thousand pounds show that you are not accustomed to the STANDARD treatment of a private hospital or what is expected for that rate at any 4* hotel. The article was about the tragic death of Violet Stephens,but I guess you feel so much about YOU and what you got for your Nira that you can’t even offer a R.I.P.

The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline.

Views: 0

You can skip to the end and leave a response. Pinging is currently not allowed.

Leave a Reply

Powered by WordPress | Designed by: Premium WordPress Themes | Thanks to Themes Gallery, Bromoney and Wordpress Themes