Pictures Above - Gillian Nelson, Mother
On 7-10 April 2015 Her Majesty's Senior Coroner Andrew Harris will conduct an inquest touching the death of Gillian Nelson who died following the birth of her son at PRUH.
Gillian was in her early 30s and had been admitted to PRUH for the induction of her first child on 27 January 2014. During labour the CTGs indicated foetal distress but were not acted on until much later in time. Reports of maternal bleeding were not recorded contemporaneously and only discovered after the birth. Towards the end of labour her baby's condition deteriorated and there was an urgent forceps delivery. However, notwithstanding a huge blood loss during delivery of at least 800ml, it was not appreciated that she had started to haemorrhage, possibly due a uterine abruption. By the time the level of haemorrhaging was appreciated her condition was critical, and lifesaving surgery had to be carried out. However, her condition deteriorated further and it was ultimately not possible to save her.
She leaves a husband and young son for whom the loss of Gillian will never be replaced.
Until the Coroner's hearing has been completed it is not appropriate to comment on what his findings as to the cause of death might be, but it is fair to say that the family hope and believe that he should find that the care provided to Gillian was lacking in skill and effectiveness. Her death, they believe, was wholly avoidable had there been effective communication between the different clinical teams caring for Gillian creating joined up care that picked up on problems during labour, so that the risk of haemorrhage was foreseen, and the symptoms of haemorrhage recognised and acted upon promptly.
The PRUH has been run by King's College Hospital NHS Trust since October 2013 and recently Monitor announced it would be reviewing its operations,  which intervention Kings have welcomed in a press release on their website. Its maternity services will also be reviewed as part of the NHS England national review of maternity care, ordered in the wake of the Morecombe bay report.
The family will not be answering any questions directly and all enquiries should be channelled through Caron Heyes of Fieldfisher Solicitors who is representing their interests at the inquest.
Caron Heyes, their solicitor, adds:
In Feb 2014 the CQC published an inspection report of an inspection carried out in early December 2013, nearly 2 months before Gillian's death. http://www.cqc.org.uk/location/RJZ68. The CQC report referred to a new transfusion procedure and that most staff had not attended the training for it in December 2013. It referred to limited availability of Obstetric consultant cover, inadequate midwifery staffing levels and a lack of risk management in the hospital as a whole.
They said of maternity services:
"…we found a number of areas that require improvement. Although staffing levels had been improved, they need further enhancement in terms of skill mix and experience. Consultant cover at the weekend is only part time".
"…Staffing levels had been increased, but there were insufficient staff with supervisory skills and expertise to support midwives as well as insufficient staff for the ratio of births to midwives."
It is clear that only 2 months before Gillian was a patient at PRUH there were serious ongoing problems with availability of consultant level care, staffing and training. Read in conjunction with Gillian's story, it seems that there are good reasons to be concerned as to the adequacy of her care.
We cannot speculate, 2 weeks before the inquest, on the likely findings of the Coroner, but we anticipate that all interested parties will gain a better understanding of whether different care and services would have prevented her death. That process of understanding what care she did or did not receive, whether her death was avoidable and whether future similar deaths can be avoided is of huge importance to the family.
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