A married mum-of-three whose 'smile lit up every room' tragically died after developing severe sepsis following a hospital procedure, an inquest has ruled.
An inquest into the death of Situl Kaur Bains found the complication was extremely rare.
Mrs Bains was in good health when she became pregnant in 2020 but, sadly, the baby was found to have brain abnormalities.
The couple made the difficult decision to terminate the pregnancy at 24-plus weeks.
Mrs Bains, 37, was given a drug to stop the pregnancy and it was explained there was a risk of bleeding and a need for further surgery.
No leaflet was given to the family describing the procedure she underwent and it did not exist at the time but does now.
Details of the procedure were poorly recorded, the Nottingham inquest was told, and blood samples were not arranged to go to the lab urgently, when she became unwell, and an anaesthetic review was one hour later than should have happened.
But the development of sepsis in highly successful lawyer Mrs Bains was so rapid and unlimiting, and all was done to save her life.
Dr Elizabeth Didcock, the assistant coroner for Nottinghamshire said: "Whilst it is the procedure that led directly to her death, there is no evidence the procedure was performed incorrectly or inappropriately."
While she acknowledge there was "some delay" in investigation and anaesthetic review, there was no evidence this caused or made a contribution to her death.
A bug, called Clostridium infection, was likely to have been introduced into the baby at the time of the procedure, according to the pathologist.
The likely explanation for this was a needle used in the procedure traversed the bowel and extradited the bug to the baby.
A bowel injury is very rare but a recognised complication of the procedure.
Dr Didcock said she accepted: "At this time there had never been a complication of severe sepsis following this procedure in Nottingham."
Mrs Bains was part of a large and supportive extended family.
They had described how her smile "lit up every room" and her "presence was palpable" and was "beautiful inside and out".
Described as a devoted mother of three young children, she was ambitious, driven and capable.
"She took every opportunity to laugh with her children and talk to them and surround them with love," read the tribute.
She was a highly accomplished and a hugely successful lawyer and "she was beautiful both inside and out".
"She was a phenomenal human being and did not deserve this fate," the tribute added,
Mrs Bains had previously been recognised at the Nottingham Post Women in Business Awards, winning Female Executive of the Year in 2017 during her time with UNiDAYS.
UNiDAYS, named Company of the Year at the 2018 Nottingham Post Business Awards, provides students with discounts on brands including ASOS, Apple, EE and Microsoft.
What tragically happened
After the procedure, Mrs Bains' observations were "normal" and she left the Queen's Medical Centre, Nottingham, to return for the second stage.
But Mrs Bains, who had initially been well in the night, complained of shivering and being in severe abdominal pain, which her husband, Baljit Singh Bains, described as "horrendous".
They returned to the QMC where she developed a rash and high temperature.
She had developed a condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels, and sepsis.
She was taken into surgery for an emergency C-section and a hysterectomy but, despite all efforts to save her, she had a heart attack and passed away.
Subsequently, the Healthcare Safety Investigation Branch launched an investigation, and the report is yet to be finalised, the inquest was told.
Dr Didcock recorded a narrative verdict on Thursday, January 27.
She accepted that the infection following the injection procedure "is extremely rare" but she found "this is the most probable explanation in this case" with the alternative theory of ascending infection, put forward by four obstetric consultants, less likely.
The medical cause of death was (1a) multiple organ failure; (1b) systemic sepsis; (1c) Intrauterine infection at 24 weeks ingestation following the procedure.
Dr Keith Girling, medical director at Nottingham University Hospitals, said: “We would like to offer our sincerest condolences to the Bains family, we are truly sorry for what happened, and our thoughts remain with them at this difficult time. This was a tragic outcome following a rare and complex procedure, and we have carefully reviewed the events to find any learning that could benefit patients in similar circumstances in the future.”
Officials at NUH have developed a local safety standard and standard operating procedure for invasive procedures.
This includes consideration of a ‘stop point’ in this complex procedure, as was conducted in this case, the trust confirmed.
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