Experts probe mum's death

INDEPENDENT experts have carried out a full investigation into the tragic chain of events which led to the death of an Ipswich woman just hours after giving birth.

Richard Cornwell

INDEPENDENT experts have carried out a full investigation into the tragic chain of events which led to the death of an Ipswich woman just hours after giving birth.

Ipswich Hospital has received a series of recommendations for changes to its procedures and has already put those in place to try to ensure a similar incident never happens again.

Jan Rowsell, head of communications, said a “highly unusual set of circumstances” had led to the death of 23-year-old Joanne Whale.

Experts from other hospitals had looked into the situation to see what lessons could be learned.

Ms Rowsell said: “In future, there will be a continuous risk assessment where a home delivery has been requested over the appropriateness of a home delivery - no one size fits all and this will be done in every single case with each person's circumstances looked at carefully.

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“This will be done in the beginning, during the pregnancy and nearer the birth, a continuous assessment because circumstances do change.”

The inquest was told doctors did not know the exact nature of Miss Whale's condition.

However, Ms Rowsell said it had not been easy for the midwife, a trained professional who has not been subject to any disciplinary proceedings, as it was a very rare complication.

She said: “This was a tragic chain of events and a highly unusual set of circumstances - everyone involved was devastated by what happened.

“We extend our sincere condolences to all family members.

“Of course, we can never ever say something like this would not happen again, but we have tried to eliminate and improve wherever we can.”

Improvements would also take place to ensure information was passed correctly and acted upon between different agencies. Ambulance staff had asked for the maternity block lift to be held ready for their arrival, but while this information was received it was not done, wasting valuable minutes.

JOANNE Whale died just hours after giving birth at home following a communication breakdown between doctors and midwives, an inquest has heard.

Miss Whale, 23, from Ipswich, suffered a “massive haemorrhage” because of complications as she gave birth to a healthy baby on September 10 last year.

Despite paramedics taking her to hospital, doctors were not informed of the exact nature of her condition - leading to a delay in getting her into the operating theatre. Miss Whale, of Whitworth Close, died six hours after the birth.

Yesterday, Greater Suffolk coroner Dr Peter Dean said “lessons needed to be learned” from the tragedy.

Giving evidence at the hearing, held at Ipswich Crown Court, midwife Sarah Hall admitted she did not pass on information that Miss Whale, a childminder, had suffered an “inverted uterus” during labour.

Balroop Johal, consultant gynaecologist at Ipswich Hospital, said: “The staff were expecting a retained placenta. If they had been told it was a complete inversion of the uterus then she would almost certainly have gone straight to theatre and I would have been ready for her.”

The inquest also heard midwives supervising the home birth - along with the technician paramedic who was first to arrive following the 999 call - were not capable of injecting fluids into Miss Whale as she started to lose blood, a procedure known as canulation.

Midwife Julie Bates said although she was trained in the process, she had never been called to put it into practice.

“I've got the theoretical knowledge but not the practical knowledge,” she told the inquest. “I felt uncomfortable having to do that in this situation.

“Knowing the ambulance was only a few minutes away I thought it was better to leave it for the proper paramedics who have expertise in this on a daily basis.”

Dr Dean recorded a narrative verdict of death from complications following an obstetric home delivery. He called for lessons to be learned following the tragedy and said he was “surprised” that midwives would not be confident in injecting potentially life-saving fluids.

He also said the public needed to be better informed about the possible dangers of home births and communication between healthcare professionals improved.

A spokeswoman for Miss Whale's family said they remain “devastated by her loss” and wished to continue to grieve in private.