Serious errors from senior staff members at Bassetlaw Hospital led to the death of a "kind and caring" mum after she gave birth, an inquest has found. Jade Hart, who was originally from Pontefract in West Yorkshire, gave birth to her son Hugo just after 10pm on July 8, 2018, at the hospital in Worksop.
Hours later, in the early hours of July 9, she died, having suffered a uterine inversion, a rare complication in which the uterus turns partially or completely inside out. An inquest at Nottingham Coroner's Court has concluded this occurred as a result of mistakes carried out by one of her doctors and a midwife at the hospital.
The 33-year-old's umbilical cord was found to have been pulled at least four times by a doctor when her placenta had not separated, an action which Assistant Coroner Dr Elizabeth Didcock labelled as "a very serious omission of care" and led to Mrs Hart's death. Mrs Hart suffered multiple cardiac arrests and would not have died if it were not for the uterine inversion, the inquest found.
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The inquest also found that the mismanagement of her ongoing hemorrhage also contributed to her death, with regular checks not undertaken in the hours leading up to her death. She had lost at least 5.5 litres of blood and eventually experienced organ failure and brain damage, with neglect contributing to her death.
These individual mistakes could not have been foreseen by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, the inquest concluded, and came instead as a result of guidance not being followed. The trust was criticised by the coroner for a report passed on by them to medical bodies afterwards, which omitted criticism and analysis undertaken by an independent expert.
Julie Hazelgrave, Jade's mother, said after the inquest: "Jade was wonderfully kind and caring with a great zest for life. In July 2018, with her husband, Jade walked into Bassetlaw hospital full of excitement and anticipation for the birth of their baby. Jade had a perfect life and marriage and, when their son was born, I saw that Jade was the happiest she had ever been.
"Cruelly, all happiness was short-lived when, within one hour of birth, Jade collapsed and died in the immediate hours thereafter. We remain devastated at the loss of Jade. Her death has cast a long shadow over our lives and our world has irrevocably changed. We miss Jade every single day and always will."
After being taken up to the intensive care unit, Mrs Hart became extremely unwell and later died. A well-respected expert, who undertook an independent review of Mrs Hart's death and its circumstances, concluded that Jade's doctor had breached their duty of care - and their actions went "well below" what would be expected of them.
They added that it was a "truly exceptionally bad" decision that would result in a "serious risk of death". The same expert also concluded the mismanagement of Mrs Hart's hemorrhage also represented a gross breach of duty.
Meanwhile, Jade's husband Richard Hart said: "Being independent and thorough, Jade's inquest has been invaluable to our understanding of what happened to Jade, that turned what should have been a wholly wonderful day into one with tragedy. Ascertaining the facts is important, not least for our son who now has to live his life without his mummy." Thanking the family's legal team, coroner and those staff who did respond and care for Jade appropriately, he added: "It is time to find some peace and time to grieve the gift that was Jade, while concentrating on the joy and gift that Jade gave to us, our beautiful son."
Mr Hart, who remained in the room with his wife and Hugo the entire time before she was taken away after falling seriously ill, said he had no recollection of her being asked to push, or making sounds to suggest she was pushing, after the birth, as was initially suggested by her doctor. Mrs Hart was said to be previously well before the incident, however, she did have high blood pressure prior to labour being induced.
Before giving birth, Mrs Hart had asked for an epidural which had been rejected over fears around her high blood pressure - the inquest found this request should have been granted and would have offered her some pain relief. A failure to properly control her blood pressure, meanwhile, was found to have likely not contributed to her death.
Dr Didcock criticised the hospital's trust for a report written after the incident and given to medical bodies, which she said did not include any recommendations or analysis from the expert who provided an independent review into what happened. Dr Didcock told the inquest: "Serious omissions has led to insufficient learning and no acceptance that this had caused serious distress to the family. This poses a risk of similar deaths occurring in the future. I am not reassured the necessary actions are in place."
She told the family: "I'm so sorry for your loss. It's also my hope that lessons will be learned that will lead to improvements in care going forward."
Jade Hart's cause of death was given as brain injury, multiple cardiac arrests and uterine inversion from inappropriate management during third stage labour.
The Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust was contacted for comment.
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