A mother died during her second pregnancy after a Caesarean was delayed because her notes were not updated properly, a coroner ruled. Rachael Chloe Walker, who was known as Chloe by her friends and family, died from severe bleeding during the 37th week of her pregnancy - which was conceived through IVF.
The 36-year-old was high risk for problems with her placenta, but her delivery plan that stated she should have a Caesarean section booked in was not recorded on her medical records. National guidance stated that a patient with Chloe's condition should have a Caesarean between week 36 and 37 and she was due to have a C-section at the 38th week.
Ms Walker was rushed to Royal Derby Hospital's maternity unit in an ambulance after suffering an antepartum haemorrhage at home in the early hours of June 19, 2021. At hospital she suffered a further haemorrhage and was taken for an emergency Caesarean.
Her baby daughter was delivered successfully, but Chloe quickly went into the first of three cardiac arrests and died just hours later in the operating theatre despite prolonged resuscitation attempts. Now a coroner has said she would likely have survived if there had not been these "missed opportunities" as either delivery would have taken place before June 19 or her haemorrhage would have happened in hospital and could have been managed better, an inquest heard.
Coroner Peter Nieto ruled it was 'probable' her death would have been avoided if a delivery plan made for her had been recorded in her notes and acted upon. He also said a contributing factor was the trust not sticking to national guidance issued in 2018 that advised for earlier Caesarean for women diagnosed with placenta praevia - a condition where the placenta partially or completely blocks the neck of the uterus, which can affect delivery.
Mr Nieto wrote a letter to University Hospitals of Derby and Burton NHS Foundation Trust with a string of recommendations. These included noting down and passing on to clinicians information given by paramedics and stopping delays in calling for the on-call consultant anaesthetist once an emergency C-section had been called.
The coroner also recommended a 'robust system' be put in place for when a patient suffers a major obstetric haemorrhage to prevent delays in getting blood. It was also discovered there was insufficient co-ordination and oversight of the emergency team and that certain key equipment was not available for the maternity theatre, including a blood storage fridge.
Chloe suffered a placental haemorrhage and amniotic fluid embolism and was diagnosed with placenta previa during her antenatal care, the inquest heard. Mr Nieto wrote in his letter to the trust: "It is probable that her death would have been avoided if a delivery plan made for her had been recorded in her notes and acted upon, and if the relevant trust had incorporated national guidance issued in September 2018 which provided for consideration for earlier Caesarean delivery.
"On the evidence it is not apparent that there was a postpartum haemorrhage, but she did develop blood clotting disorder and disseminated bleeding, likely related to the placental haemorrhage and amniotic fluid embolism. Chloe sadly died in the operating theatre despite prolonged resuscitation attempts.
"Chloe had recognised risk factors in her pregnancy and the consultant obstetrician with lead responsibility for her care decided at an appointment at week 34 of Chloe’s pregnancy on a plan to review Chloe at an appointment at week 37, with a view to offering hospital admission and planned caesarean section by week 38 due to the placenta previa.
"That plan was not recorded in Chloe’s notes with the result that the obstetric registrar who saw Chloe at week 37 was unaware of the plan. Furthermore, the hospital trust had not adopted national guidance issued in September 2018 for consideration of delivery by caesarean section between weeks 36 and 37 in Chloe’s circumstances.
"Consequently, Chloe was booked for a planned caesarean section at week 38 as per trust guidance. At inquest the trust accepted these were missed opportunities to avoid Chloe’s death and had they not been missed it is likely that Chloe would not have died because delivery would have occurred well before June 19, or, if antepartum haemorrhage had occurred during admission, it would have been successfully managed."
The corner added that he was concerned whether any new processes had been put in place since Chloe's death. He added: "My principal concern is that having heard evidence from the trust as to ‘lessons learnt’ and its current processes for identifying when trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe.
"Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death. It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into trust policy and guidance.
"I was told that introducing revised guidance was necessarily complex and lengthy and yet the trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the trust had established a regional pregnancy service using out of date guidance.
"Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process - for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest.
"I therefore consider that the trust should review its processes for identifying when trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions."
In response, the trust said it was taking the recommendations seriously and is addressing the review's immediate points, including refining its existing major haemorrhage guidance, enhancing emergency bleep - or emergency - process and putting a 'comprehensive' plan in place to rapidly deliver all other actions within the next three months.
A spokeswoman added that the trust is examining the prevention of future death report to further review its processes and improve.
Garry Marsh, executive chief nurse at University Hospitals of Derby and Burton said: "Our heartfelt condolences are with Chloe's family. The care we provided fell short of the standard our patients deserve for which we are very sorry.
"We accept there were missed opportunities and we have already acted on the learning from this sad case, which was recently reviewed as part of an independent maternity learning review that the trust requested.
"All of the immediate safety recommendations from the review are being addressed, many of which the coroner referenced during the inquest into Chloe's death, and we will continue to make further improvements to the safety and experience of women under our care.
"We are fully engaging with the prevention of future death report as a further opportunity for us to review our processes and make improvements."
Mr Nieto gave a narrative conclusion to the inquest and marked the cause of death as a placental haemorrhage at 37 weeks of pregnancy, along with an amniotic fluid embolism and placenta praevia.
