A TRAGIC mum who begged bungling medics “don’t let me die” after giving birth to her fifth child was the victim of “basic failures”, a report said.
Laura-Jane Seaman died at Broomfield Hospital, Chelmsford, Essex, after suffering a peritoneal haemorrhage.
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In a prevention of future deaths report, a coroner said the bleeding was not identified despite the 36-year-old, from Witham, telling staff she was “gushing”.
Essex coroner Sonia Hayes said in the report that Laura’s maternal collapse was “categorised by staff as a faint” when it should have been escalated to the critical care team, reports the BBC.
Mid and South Essex NHS Foundation Trust said it was improving training “to prevent this from happening again” following the incident on December 23 2022.
Laura-Jane was admitted to the hospital two days before her death and the birth of her child ran smoothly, going on to breast feed her baby.
However, the mum subsequently suffered a haemorrhage that was not picked up by medics for hours – despite her having a well-documented history of such post-birth bleeds.
She was considered at high risk of postpartum hemorrhage.
Carers initially “gave her biscuits” and thought she had simply fainted as she slipped out of consciousness.
Coroner Ms Hayes said during an inquest earlier this year evidence shows multiple “gross failures” by healthcare professionals and concluded Laura would have survived if they were handled correctly.
The court previously heard how the mum arrived shortly after 11pm on December 20 before having an “uneventful” birth with a “normal amount of blood loss”.
In the immediate aftermath, however, in the early hours of December 21, Laura-Jane had “normal” observations, had breast fed her baby and discussions took place about her going home.
But in the following hours, her condition worsened.
The court heard Laura-Jane told hospital staff she felt a sense of “bleeding” and “gushing”, saying to staff “please don’t let me die”.
She also had a feeling of impending doom, yet these alarming statements didn’t lead to appropriate escalation.
She also stated she felt dizzy, and there should have been vital signs taken at this point – instead Coroner Hayes said she was “given biscuits”.
The coroner said if her vital signs had been taken at this time, they would have been “deranged” and the case would have been escalated.
She highlighted “significant missed opportunities” to help Laura-Jane, and that her case should have been escalated far sooner.
‘NOT APPROPRIATE’
Once she became unresponsive, the staff believed she had “fainted”, despite the coroner saying it would have been “very rare to have someone faint in bed”, and that it was “not appropriate” to view this as a faint for nearly three hours.
Coroner Hayes continued: “There was an assumption that the case [was a] faint without any diagnosable cause.
“There was no definitive diagnosis. Identifying the cause was essential.
“The failure to treat the marital collapse [at 3.45am] was a significant omission.
“Laura-Jane should not have been left with no emergency review when the signs indicated she was seriously unwell.”
The coroner added that a 2222 hospital call – which summons help in an emergency – should have been made far earlier.
The fact that Laura-Jane had been bleeding “for several hours” showed her death was “avoidable”, the court heard.
Coroner Hayes said there was “sufficient time to take action” and that Laura-Jane’s own concerns about her health were not being “adequately considered”.
What’s normal and what’s not after giving birth
YOUR BODY goes through a lot when giving birth and it’s normal to notice some lingering symptoms from it – from soreness, to tiredness and emotional changes.
Stitches
If you’ve had stitches after tearing or an episiotomy (cut), bathe them every day to help prevent infection. Have a bath or shower with plain warm water then carefully pat yourself dry.
If your stitches are sore or uncomfortable, tell your midwife.
Stitches usually dissolve by the time the cut or tear has healed, but sometimes they have to be taken out.
Going to the loo
You probably won’t have a poo for a few days after the birth, but it’s important not to let yourself get constipated.
Eat plenty of fresh fruit, vegetables, salad, wholegrain cereals and wholemeal bread, and drink plenty of water.
Talk to your midwife or GP if you have constipation that won’t go away. A gentle laxative may help.
Also tell your midwife or GP if poo is leaking or you’re pooing when you don’t mean to.
Also tell your midwife if:
- you’re finding it really difficult to pee
- you feel very sore
- you notice an unpleasant smell
Bleeding
You’ll bleed from your vagina after the birth, which will be quite heavy at first, and you’ll need super-absorbent sanitary towels.
Change them regularly, washing your hands before and afterwards.
You may notice the bleeding is redder and heavier when you breastfeed. This happens because breastfeeding makes your womb contract. You may also feel cramps similar to period pains.
The bleeding will carry on for a few weeks. It will gradually turn a brownish colour and decrease until it finally stops.
If you’re losing blood in large clots, tell your midwife.
Source: NHS
A medical cause of death was given as 1A disseminated intravascular coagulation resulting from a secondary cause of medical complications following her birth.
In her conclusions, Coroner Hayes found that Laura-Jane had been neglected before her death resulting in her then compiling the report, released this week.
She said the mum had died as a consequence of “basic failures” by staff to “recognise and escalate” her loss of consciousness as a maternal collapse and “inability to obtain vital signs that were incorrectly attributed to malfunctioning equipment”.
She added that the risk to Laura-Jane’s life would have been “obvious” from vital signs obtained over the course of two and a half hours.
Diane Sarkar, Chief Nursing and Quality Officer for the Mid and South Essex Hospitals Trust, previously said: “We extend our sincerest sympathies and condolences to the family of Laura-Jane. Her tragic death has affected us all at the trust greatly.
“Following investigations into the circumstances that led to her death, 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.
“We thank the coroner for her detailed review and have listened carefully to her comments and the evidence heard at inquest, all of which will inform our efforts to continue to improve maternity services at the trust.”
The Sun has approached the trust for further comment.
