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‘Errors’ led to mum’s death
Tragedy: Julie Ellison died, along with her unborn baby, after what coroner Dr James Adeley called a catalogue of errors
A coroner has highlighted “serious failings” in the midwifery care of a mum-to-be who died from an infection at hospital.
Julie Ellison, 31, and her unborn daughter Jessica died when Julie, formerly from Longridge, contracted a severe generalised infection and was admitted to the Royal Preston Hospital in December 2010.
But Lancashire coroner Dr James Adeley said there was a “catalogue of errors” at senior midwifery level, adding had the necessary reviews been undertaken, baby Jessica would have probably survived.
Lancashire Teaching Hospitals NHS Foundation Trust has now accepted full responsibility for its failings.
Karen Partington, chief executive, said: “We offer our condolences and sincere apologies to Julie Ellison’s family.
“Our investigation identified failings in the care we provided to Julie and to her unborn baby, for which we have accepted full responsibility.
“In the past 18 months we have improved our processes, and provided additional training to all staff involved in the care of unwell pregnant women.
“We would like to assure our local communities that lessons have been learnt, and that our maternity services consistently meet and exceed national standards. This has been a very difficult period for Julie’s family and our thoughts are with them at this time.”
The inquest was told that although Julie, a purchasing engineer, of Northway, Broughton, “was very poorly” she had not presented with any obvious clinical symptoms.
She had been admitted to the hospital two days earlier with suspected Swine Flu but tests had not confirmed the disease when she was transferred to the maternity unit.
Hannah Cahill, a midwife at the hospital, said she took the chart to the ante-natal ward to be assessed by senior staff because she was concerned about the results.
But it was between four and five hours before consultant obstetrician Sean Hughes, who was in theatre all afternoon, was able to see Ms Ellison.
He said: “I expected to see someone who was more ill, but she was eating and drinking a sitting up in bed.
“We didn’t know then whether or not she would test positive for swine flu, which can have a disproportionate effect on pregnant women.
He said that because she seemed to be getting better he was optimistic and would have allowed her to go home the next day if she had no respiratory problems.
However, he said that when he saw the family the following day, by which time the baby had died, he told them that it may have survived had Ms Ellison been induced.
He said: “I should have asked for another scan, which might have helped us decide to move her to the labour ward.”
Mr Hughes said he could not explain why he had failed to note two unexplained falls in her baby’s heart rate.
He added: “Why didn’t I spot it? I don’t know. I can only apologise.”
Julie, who was deaf, was 38 weeks pregnant and suffered from a rare muscle condition, called malignant hyperpyrexia, but medics do not believe that led to her death.
Consultant physician in respiratory medicine Dr Aash Vyas said he saw Julie while she was on the medical assessment unit and found no evidence of breathing problems or high temperature.
He said he was aware from patient notes that various tests had been ordered.
Shortly after being transferred to the maternity unit her baby girl was found to be dead in the womb.
Doctors felt that she should deliver the baby but were concerned because she was ill, but didn’t know what was wrong with her.
Consultant obstetrician Fiona Crossville and Anna Bewley, a consultant anaesthetist both told the hearing in Preston that there was no obvious reason as to why the baby had died, or what was wrong with mum.
Dr Bewley said that the medical team had decided to induce the delivery of the unborn baby before Julie got any sicker and had planned to transfer her to the critical care unit.
A post mortem examination found she died from septicaemia but the source of the bug was unclear
Recording a narrative verdict, Dr Adeley said: “Julie Anne Ellison died whilst 38 weeks pregnant with baby Jessica due to a severe generalised infection of unusual presentation.”
Speaking after the verdict, Julie’s devastated partner Tom Howe, said: “When you go to hospital you expect the best level of care. Julie didn’t get this.
“She touched the hearts of many people more than she probably realised.
“Julie, her son Richard and our baby had a bright future together. This was extinguished on December 20 2010, a painful day in all our hearts.”
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Wednesday 19 June 2013
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