P R I VAT E
New complaints system
NEWSLETTER
Clinical Negligence
On April 1st this year yet another new NHS complaints system
came into operation that allows patients for the first time to
take legal action at the same time as pursuing a complaint.
Issue: Spring 2009
Under the old system patients who had started, or intended,
to launch an action for damages for clinical negligence were
barred from using the complaints process.
The new system has only 2 stages: resolution by the local trust with
a right to review by the Ombudsman, and replaces the previous
3 stage system that included an independent review by the Health
Care Commission.
The new regulator, the Care Quality Commission, which has
subsumed the Health Care Commission, will not be involved in
complaints handling.
If you would like to receive the Clinical Negligence Newsletter
by email please contact [email protected]
Please note that by providing your email address you agree to receive email
communications from JMW which you can opt-out of at anytime.
Maternal Deaths
Welcome to the Spring edition of the JMW Clinical
Negligence newsletter.
Global maternal mortality is about 600,000 per year according
to a United Nations report, but only about 1% of these deaths
are in the developed world.
There has been a steady decline in the maternal mortality rate
in the UK over many years largely due to better pre natal care,
asepsis, blood transfusion and the availability of caesarean
section. However, the rate is now plateauing and one of the
reasons for this is the increase in older mothers, some of
whom have pre existing medical conditions. Diabetes and
obesity in pregnancy is also steadily increasing.
The pattern of maternal mortality has changed markedly over
the past half century and surgical causes, such as postpartum haemorrhage and ruptured uterus are no longer as
important as medical causes. The leading cause of maternal
death in the West is now heart disease.
Manchester Office: No 1 Byrom Place, Spinningfields,
Manchester M3 3HG. t. 0845 402 0001 f. 0161 828 1827
dx. 14372 MCR 1 e. [email protected]
www.jmw.co.uk
Every death associated with pregnancy in the UK is
investigated in depth and The Confidential Enquiry into
Maternal and Child Health 2007 states that the majority
of preventable maternal deaths in the UK occurred after
sub-standard medical and/or midwifery care.
Occasionally maternal death arises where there has been
negligent care. This issue of our newsletter looks at two
such cases.
JMW Solicitors LLP is a limited liability partnership registered in England and Wales under registration
number OC338958. Registered office: 1 Byrom Place, Spinningfields, Manchester M3 3HG. A full list of
members is available at the registered office. Any reference to a Partner of JMW Solicitors LLP means a
member, employee or consultant of JMW Solicitors LLP. Regulated by the Solicitors Regulation Authority.
jmw.co.uk
Maternal death case 1
Maternal death case 2
W was 35 years old when she died in 2002. She had a
congenital cranio-facial abnormality known as Pierre Robin
Syndrome and one of her 3 children was also affected.
31 year old M had been treated for epilepsy as a child
but her medication had been discontinued after a number
of years.
In 2001 W became pregnant again and ante-natal investigations
showed that the fetus had a severe form of Pierre Robin
Syndrome with major deformities of the chest and mandible.
Because of this an elective caesarean section was planned
with ex-utero intrapartum treatment (EXIT). This is a method of
maintaining the utero-placental circulation during caesarean
section to allow an airway to be established in the baby prior to
delivery, thereby avoiding hypoxia
However, she continued to experience periods of faintness
and vacancy whenever she was stressed, tired or hungry.
It was uncertain whether these were epileptiform in nature
or pseudoseizures/panic attacks.
The procedure was undertaken without apparent complications
on August 1 2002 and a redivac drain was inserted into the
peritoneal cavity because of the risk of post operative bleeding.
After the drain was removed the following day W became
increasingly distressed with abdominal pain and distension.
Acute bowel obstruction was suspected but the opinion of a
specialist surgical registrar was that her symptoms were due to
a post-operative ileus, so no action was taken.
W appeared to be making slow progress and was beginning to
eat and mobilise. However, she had a persistent tachycardia,
elevated white cell count, increasing abdominal distension and
oedema of the abdominal wall and legs resulting in blistering.
These very abnormal symptoms persisted without further
investigation until August 12 2002 when there was a sudden
deterioration in W’s condition. She had acute abdominal pain,
a rigid tender abdomen and a clinical and biochemical picture
consistent with sepsis.
A laparotomy was performed the following day and signs of
generalised peritonitis were found with 2 litres of pus and fluid in
the abdominal cavity and “an obvious perforation of the lateral
wall of the caecum”.
Very unfortunately W developed acute multi organ failure and
died on August 30 2002. Her children were left in the care of
their maternal grandmother.
She was referred for cardiological and neurological
assessment but nothing was found to explain these episodes.
When M was 33 weeks pregnant in 2007 she had 2 episodes
of palpitations and fainting (syncope) but it appears that the
midwives were unaware of her long history of similar attacks.
When M was admitted in labour on 1 June 2007 she explained
to the midwives that she often felt faint when under stress,
but the possible consequences of this were not fully
appreciated. She was agitated and had not eaten for
some time.
At approximately 2045 M requested to have a bath to
help with labour pains and went alone to the bathroom.
She was not considered to be at any particular risk and
was left unattended.
At 2140 hours, after a change of nursing shift, a friend went
to look for M and found her submerged in the bath,
pulseless and not breathing. She was resuscitated by the
‘crash’ team and an emergency caesarean section performed
at 2151 resulting in the birth of a healthy baby boy.
Tragically M had sustained severe hypoxic brain damage
while submerged in the bath water and on 9 June 2007 her
ventilator was switched off .
At the inquest the coroner recorded an Open Verdict as he
considered the cause of death “unascertained”.
M’s husband intends to take legal action against the Trust on
the basis that, given his wife’s history of fainting attacks,
she should not have been left unattended while taking a bath.
It was alleged that there was a failure to ensure daily clinical
review of W’s deteriorating condition and to consider abdominal
pathology other than an ileus and to conduct a CT scan.
It was further alleged that had W received an appropriate
standard of care she would have undergone an exploratory
laparotomy at some point prior to August 13 and her life would
have been saved.
Breach of duty was admitted by the defendant and the case
was settled for £275,000.
jmw.co.uk