Young mum died after errors - inquest

A YOUNG mother died just hours after giving birth at home following a communication breakdown between doctors and midwives, an inquest has heard.

A YOUNG mother died just hours after giving birth at home following a communication breakdown between doctors and midwives, an inquest has heard.

Joanne Whale, 23, from Ipswich, suffered a “massive haemorrhage” because of complications as she gave birth to a healthy baby on September 10 last year.

She was rushed to hospital by paramedics, but an inquest heard today how doctors were not informed of the exact nature of her condition - leading to a delay in getting her into the operating theatre.

Childminder Miss Whale, from Whitworth Close, died six hours after the birth.

Greater Suffolk coroner Dr Peter Dean said “lessons needed to be learned” from the tragedy.

Giving evidence at the hearing, held at Ipswich Crown Court, midwife Sarah Hall admitted she did not pass on information that Miss Whale had suffered an “inverted uterus” during labour.

Most Read

Marlar Raja, a specialist registrar in gynaecology at Ipswich Hospital, said the patient would have been taken straight to theatre if she had been made aware.

Her colleague Balroop Johal, consultant gynaecologist at Ipswich Hospital, added: “The staff were expecting a retained placenta. If they had been told it was a complete inversion of the uterus then she would almost certainly have gone straight to theatre and I would have been ready for her.”

The inquest also heard midwives supervising the home birth - along with the technician paramedic who was first to arrive following the 999 call - were not capable of injecting fluids into Miss Whale as she started to lose blood, a procedure known as canulation.

Midwife Julie Bates said although she was trained in the process, she had never been called to put it into practice.

“I've got the theoretical knowledge but not the practical knowledge,” she told the inquest. “I felt uncomfortable having to do that in this situation.

“Knowing the ambulance was only a few minutes away I thought it was better to leave it for the proper paramedics who have expertise in this on a daily basis.”

Paramedics were also delayed in taking the young mother to hospital after problems removing her from an upstairs bedroom at her home, the inquest heard.

Martin Hambling, who was in the first of two ambulances to arrive, said: “Extraction was extremely difficult because of the layout of the house. We had to negotiate several sharp turns while also trying to maintain the patient in a flat position.”

Pathologist Dr John Chapman, who carried out the post mortem examination, said Miss Whale died as a result of the inverted uterus causing a uterine haemorrhage.

As a result of the body being in so much shock her blood lost the ability to clot and this caused extensive bleeding, the inquest heard.

Greater Suffolk coroner Dr Dean recorded a narrative verdict of death from complications following an obstetric home delivery.

He called for lessons to be learned following the tragedy and said he was “surprised” that midwives would not be confident in injecting potentially life-saving fluids.

He also said the public needed to be better informed about the possible dangers of home births and communication between healthcare professionals improved.

“I think we can see those areas where lessons need to be learned,” he said. “It does worry me a lot that mothers are giving birth in the community and the first line of call is the midwife who might not be able to get fluid into her in those crucial early moments. Clearly that needs to be addressed.

“We can't be certain that, had these things been done, she would have survived. All we can say is the chances of survival would have been greater.”

Following the hearing, a spokeswoman for Ipswich Hospital said: “This is a tragic chain of events in a highly unusual set of circumstances. We extend our sincere condolences to all family members.

“The hospital has carried out a thorough clinical investigation and asked independent colleagues for their judgment.

“We have put into practice all lessons learned. In particular, we have strengthened communication and introduced new protocols on midwives carrying out canulation and risk assessment around home deliveries.”

A spokeswoman for Miss Whale's family said they remain “devastated by her loss” and wished to continue to grieve in private.

Become a Supporter

This newspaper has been a central part of community life for many years. Our industry faces testing times, which is why we're asking for your support. Every contribution will help us continue to produce local journalism that makes a measurable difference to our community.

Become a Supporter