Gloucester mother died after post-birth treatment delay

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Modar Mohammednour is present  bringing up   his daughters azygous  handedly

Image caption,

Modar Mohammednour with daughters Rana and Reem

By Matthew Hill

BBC West wellness correspondent

A begetter whose woman died aft childbirth believes she would inactive beryllium live if she had fixed commencement elsewhere.

Rana Abdelkarim died astatine Gloucestershire Royal Hospital successful March 2021 aft suffering a bleed post-birth.

The Healthcare Safety Investigation Branch (HSIB) recovered determination were delays successful calling for specializer help.

Gloucestershire Royal Hospitals NHS Foundation Trust apologised and said steps person been taken to forestall akin tragedies.

Image caption,

Rana Abdelkarim died aft suffering a bleed post-birth astatine Gloucestershire Royal Hospital

Modar Mohammednour, who made a location successful Gloucestershire aft leaving Sudan with small English, said that successful March 2021, his woman attended the maternity portion astatine 39 weeks into her gestation for what she thought was a regular check-up.

Mr Mohammednour, 44, said owed to connection barriers his woman thought she was going "for a scan and to cheque connected her health" and past "come backmost home", but successful information she was being sent to beryllium induced.

"Immediately" aft the labour, Ms Abdelkarim suffered dense bleeding and her information deteriorated - thing Mr Mohammednour said helium was "unaware of", until helium was yet called into the infirmary to talk to a doctor.

The family's solicitor Hannah Carr, from Novum Law, said astatine this constituent her hubby didn't cognize she had fixed commencement fto unsocial was successful a captious condition.

According to the probe by the HSIB, the obstetric squad of elder doctors were not told astir the drastic alteration successful her information for astir 30 minutes.

'What happened to my wife?'

Mr Mohammednour said: "He [the doctor] conscionable came backmost and said to me: 'I did the champion to prevention her beingness but I couldn't'.

"I was feeling - 'I americium dreaming'. She was talking to maine yesterday. She was truthful successful bully health, what happened to my wife?".

An probe into her decease by the HSIB recovered that erstwhile Ms Abdelkarim had been fixed a drip to velocity up labour, regular enactment from midwives and assessments could not beryllium fixed to her due to the fact that the maternity ward was truthful busy.

It besides recovered determination was a 53-minute hold from the constituent of bleeding to administering the archetypal humor transfusion.

'No effectual communication'

The HSIB besides recovered Ms Abdelkarim was "uninformed" astir the crushed for her admission, "consent to induce labour was not given" and due to the fact that she was bladed and small, unit underestimated however overmuch comparative humor measurement she was losing.

The HSIB said: "There was nary effectual connection with Rana and the events that occurred traumatised staff."

Ms Carr said Ms Abdelkarim was astatine greater hazard during childbirth arsenic she had undergone pistillate genital mutilation arsenic a girl.

She said that during the commencement of her archetypal daughter, "that was a information due to the fact that Modar", who was present, "was capable to advocator for her".

Image caption,

Modar Mohammednour is present bringing up his 2 daughters alone

Ms Carr said due to the fact that Mr Mohammednour was absent successful the commencement of their 2nd girl and determination were mediocre mentation services, Ms Abdelkarim and her hubby "didn't recognize what was happening", which "resulted successful a implicit breakdown successful connection and led, unluckily successful portion to her tragic death".

She added: "The Trust's guidelines for monolithic obstetric haemorrhage and 'Code Red' were not followed.

"The exigency telephone doorbell was not activated erstwhile unit observed the mother's bleeding which meant that for astir 30 minutes the obstetric exigency was chartless but to the radical successful the mother's room."

Mr Mohammednour, who is present bringing up his 2 daughters alone, said six-year-old Reem asks him "all the clip astir her mum."

"My excuse is conscionable to accidental to her 'she is successful paradise'," helium added.

'Serious information incidents'

Interpretation problems and the handling of dense bleeds were highlighted successful a study by the Care Quality Commission, pursuing an un-announced inspection of the Gloucestershire Royal NHS Foundation Trust successful April 2022.

It recovered a precocious fig of superior information incidents involving mothers and babies.

The study besides said unit could not ever place erstwhile a woman's information was deteriorating, with women similar Laura Bowtell losing her babe Margot aft unit failed to place she should person fixed commencement successful a consultant-led unit.

The infirmary said they had implemented each 10 recommendations made successful the HSIB report.

Deputy main enforcement of the trust, Professor Mark Pietroni, said the work continues to marque improvements "in the involvement of diligent and unit safety" aft the CQC inspection, including 1 to 1 attraction successful labour.

He added: "Tragedies specified arsenic these are thankfully uncommon and it is important to accent that our maternity outcomes are successful enactment with comparable maternity units, nationally."

He said it was "vital" for the infirmary to "take each accidental to recognize the factors that mightiness person contributed to specified a tragic outcome" and to "learn and marque attraction arsenic harmless arsenic possible."

Image source, Google

Image caption,

Interpretation problems and the handling of dense bleeds were highlighted successful a study by the Care Quality Commission, pursuing an un-announced inspection successful April 2022

The latest published maternity information information from MBRRACE-UK showed successful 2020, the twelvemonth earlier Ms Abdelkarim died, Gloucestershire was 1 of conscionable six trusts successful the state that had 2 "red flag" warnings for having stillbirth and newborn decease rates much than 5% supra the mean for akin units.

In 1 lawsuit that year, baby Freddie Whewell had his skull fractured successful transportation and his encephalon was starved of oxygen.

An inquest recovered his mother, Jay Whewell, was 3rd successful the queue for an exigency caesarean and Freddie mightiness person lived had helium been delivered sooner.

MBRRACE Lead, Professor Elizabeth Draper, told the BBC, stillbirth and neonatal mortality is simply a reasonably uncommon outcome- truthful the numbers are rather debased - which means immoderate "natural variation".

'Safest imaginable service'

Professor Draper said portion being identified arsenic reddish "wouldn't needfully place them specifically arsenic a portion that has a peculiar problem", it is "really important" for those units identified arsenic reddish to "look astatine all" the "cases of inactive commencement and neonatal mortality" and "review the attraction provided for those cases".

Professor Pietroni said a reappraisal was carried retired aft the MBBRACE-UK study and the spot had "identified cardinal themes for learning and intervention".

He said the information for 2021 "shows a marked simplification successful stillbirths and neonatal deaths" and they were "absolutely committed to delivering the safest imaginable service", leaving "no chromatic unturned" successful their efforts, "including exposing" themselves to "external reviews".

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