A recent inquest has concluded that a mother’s death could have been avoided after she delivered her baby if it were not for ‘missed opportunities’.
Rachel Chloe Walker, known as Chloe, sadly died not long after giving birth at the Royal Derby Maternity Unit on 19 June 2021. The Coroner heard that the plan to deliver her baby at 38 weeks had not been added to her electronic notes and hospital staff were using outdated guidance.
It is reported Ms Walker had conceived her second child after IVF treatment and had recognised risk factors, which included placenta praevia. At 34 weeks, during a routine appointment, a Consultant Obstetrician said that Ms Walker would need to be checked in a further 3 weeks’ time with a plan to deliver the baby by C-section at week 38. This was not written in her electronic notes resulting in the Consultant Obstetrician who reviewed Chloe at week 37 being unaware of the plan. It is also reported that the Trust were not following up to date guidance issued in September 2018, which would have seen Ms walker booked for C-Section much earlier than originally planned.
In the early hours of 19 June 2021, Ms Walker collapsed at home and was taken to hospital by ambulance with heavy bleeding. Her daughter was successfully delivered by emergency C-section, however, Ms Walker suffered 3 cardiac arrests and tragically died.
The Trust accepted that there were missed opportunities to avoid Ms Walker’s death and had they not been missed, it is likely she would have survived as delivery would have occurred much sooner or, alternatively, had Ms Walker been admitted to Hospital, the haemorrhage would have likely been controlled preventing her death.
Further failings at the Trust were identified.
The Coroner issued a prevention of future death notice due to his concerns that the Trust had failed to make enough changes to its procedure.
The Trust have since given assurances that important changes are being implemented and acted upon, more so following the recent HSIB investigation.
We support many families who have sadly suffered at the hands of hospital Trust failures, in particular maternity failings leading to injury to babies, injury to mothers, maternal death and baby loss. If you have been affected by any of the above, please contact us so that we can begin to support you.