Hospital’s apology for death of mother in stillborn labour
Coroner files report to prevent similar cases
19 November, 2020 — By Tom Foot
The Royal Free Hospital in Hampstead
THE life of a mother who died giving birth to a stillborn baby could have been saved if a doctor had checked-up on her, a coroner has said.
Malyun Karama, 34, died at the Royal Free Hospital in February from a rupture caused by a drug prescribed to induce labour following a death in the womb.
St Pancras coroner Ms Hassell has now written to the hospital in Pond Street, Hampstead, warning the dose of misoprostol was “in excess of the Royal College of Obstetricians and Gynaecologists national guidelines”.
The hospital responded this week saying it had revised the way it administered the drug following an investigation.
Ms Hassell’s Prevention of Future Deaths report added: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.”
The report said that during the inquest the Royal Free gave evidence that it now made medical reviews of “multigravida” mothers.
Multigravida mothers are those giving birth for a second time and are at increased risk of uterine rupture, according to the coroner.
It added that the Free should take “steps to ensure that there is learning at a national level of the increased risk of rupture in a multigravida mother” and installed a computer in its delivery suite “to help midwives record observations”.
“In my opinion, action should be taken to prevent future deaths,” the report said.
A spokesperson for the Royal Free said: “We would like to offer our deepest condolences to Malyun Karama’s family and to apologise for mistakes made in the care we provided to her. As the result of changes made following Ms Karama’s death we make sure patients in the same situation as Ms Karama are more closely monitored. We also ensure the computer remains in the delivery suite.
“This learning has been shared across the trust and nationally.”