Mom died hours after birth when doctor’s ‘mistake’ saw uterus turned inside out
Jade Hart gave birth to her first child, Hugo, but died just hours later after ‘mistakes’ and ‘extraordinarily bad’ decisions caused her to go into cardiac arrest and lose gallons of blood
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A mother tragically died just hours after giving birth to her firstborn son after a midwife and doctor’s “mistakes” caused her uterus to turn upside down.
“Royal and caring” Jade Hart had just given birth to baby Hugo after 10pm on July 8, 2018 at Bassetlaw Hospital in Worksop, Nottinghamshire.
However, in the early hours of the following morning, she suffered a rare complication called uterine inversion, in which the uterus rotates inside out, and died as a result.
This came as a result of a series of errors committed by one of her doctors and a midwife at the hospital, a Nottingham Coroner’s Court inquiry has found.
Jade’s heartbroken mother, Julie Hazelgrave, said after the exam: “Jade was wonderfully kind and caring with a great zest for life.
“In July 2018, Jade walked into Bassetlaw Hospital with her husband full of excitement and anticipation for the birth of their baby.
“Jade had a perfect life and marriage and when her son was born I saw that Jade was happier than ever.
“Atrociously, all happiness was short-lived as Jade collapsed within an hour of birth and died in the immediate hours after. We remain devastated at the loss of Jade.
“Her death cast a long shadow over our lives and our world has changed irrevocably. We miss Jade every day and always will.”
The 33-year-old had her umbilical cord pulled at least four times by a doctor when her placenta was not separated, the investigation said.
This action resulted in Ms. Hart’s death and, according to Assistant Medical Examiner Dr. Branded Elizabeth Didcock a ‘very serious omission of care’.
The new mom also suffered a series of cardiac arrests but would not have died had it not been for the uterine inversion, the inquest found.
Mismanagement of her continued bleeding was also found to have contributed to her death, as regular checks were not carried out in the hours leading up to her death.
Ms Hart lost at least 5.5 liters of blood, and eventually suffered organ failure and brain damage, according to the exam. Neglect contributed to her death.
The individual errors could not have been foreseen by the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, the inquiry said. They came instead because the lead wasn’t being followed.
The Trust came under fire from the coroner over a report they passed to medical facilities after the incident.
Criticism and analysis by an independent expert on the incident were omitted.
The assessor who conducted the review found that Jade’s doctor had failed in his duty of care and his actions were “significantly below” what was expected of him.
They went on to say it was a “really exceptionally bad” decision that would result in a massive risk of death.
In addition, they said that mismanaging Ms. Hart’s bleeding also constituted a gross dereliction of duty.
Jade’s husband Richard Hart said: “Because Jade’s investigation was independent and thorough, it was invaluable in our understanding of what happened to Jade, which turned a wonderful day into a tragic day.
“The clarification of the facts is important, not least for our son, who now has to spend his life without his mother.”
He added, “It’s time to find some peace and time to mourn the gift that Jade was as we focus on the joy and gift Jade gave to us, our beautiful son. “
Mr Hart was in the room with his wife and baby Hugo at all times before she became seriously ill.
He said he has no recollection of her being asked to push or making noises suggesting she was pushing, despite her doctor’s initial recommendation.
Before the birth, Ms. Hart asked for an epidural, which was refused for fear of her high blood pressure.
The investigation concluded that this request should have been granted and would have provided her with some relief from the pain.
It has since been determined that a failure to control her blood pressure was unlikely to have contributed to her death.
dr Didcock criticized the hospital’s trust in a report written after the incident.
In it, she said it contained no recommendations or analysis from the expert who conducted the independent review.
dr Didcock told the Inquiry: “Serious omissions have resulted in insufficient learning and no acceptance that this had caused serious suffering to the family.
“This poses a risk of similar deaths occurring in the future. I’m not sure if the necessary action has been taken.”
She told the family: “I am so sorry for your loss. I also hope that lessons will be learned that will lead to better care in the future.”
The final cause of Ms Hart’s death was given as brain injury, multiple cardiac arrests and uterine inversion due to inappropriate treatment during stage three labour.
The Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has been contacted for comment.
https://www.mirror.co.uk/news/uk-news/mum-died-hours-after-giving-27142956 Mom died hours after birth when doctor's 'mistake' saw uterus turned inside out