Serious errors from senior staff members at a West Yorkshire Hospital led to the death of a first-time mom just hours after she gave birth, an inquest has found.
Jade Hart, who was originally from Pontefract, gave birth to her son Hugo just after 10 p.m. on July 8, 2018, at Bassetlaw Hospital in Worksop.
But hours later she tragically 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.
Assistant Coroner Dr. Elizabeth Didcock labelled the action as “a very serious omission of care” which led to Mrs. Hart’s death.
A report issued at the Inquest found that the mother had suffered multiple cardiac arrests and would not have died if it were not for the uterine inversion.
The investigation also found that the mismanagement of an ongoing hemorrhage also contributed to her death, with regular checks not undertaken in the hours leading up to her death.
Reports said she had lost at least 5.5 liters 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 allegedly responsible has since been criticised by the coroner for a report passed on by them to medical bodies following Mrs. Hart’s death.
Speaking after the inquest, Julie Hazelgrave, Jade’s mother, paid tribute to her “wonderfully kind and caring” daughter who had “a great zest for life.”
She said: “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.”
Exceptionally bad mistakes
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.
Mrs. Hart was said to be previously well before the incident, however, she did have high blood pressure prior to labor 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.
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 have been contacted for comment.