The death of a mother at the hospital where she gave birth to her fifth baby was “avoidable and contributed to by neglect”, a coroner has ruled.
Laura-Jane Seaman, 36, died at Broomfield Hospital, Chelmsford, Essex, on 23 December 2022 following a significant peritoneal haemorrhage.
Coroner Sonia Hayes found multiple “gross failures” by healthcare professionals and said if these had not occurred, Ms Seaman would not have died.
Mid and South Essex NHS Foundation Trust said it was improving training “to prevent this from happening again”.
A spokesperson extended the trust’s sympathies to Ms Seaman’s family.
Ms Seaman had been known to the Essex trust to be at high risk of postpartum hemorrhage – heavy bleeding post-birth – prior to her admission to hospital.
A three-week inquest at Essex Coroner’s Court heard Ms Seaman, who was a care support worker, had a normal vaginal delivery on 21 December 2022.
She was able to breastfeed her baby and there were discussions about her going home before her condition began to deteriorate.
There were multiple missed opportunities to recognise this appropriately and to escalate for a senior review, the inquest heard.
‘Bleeding for hours’
The coroner was told the mother-of-five repeatedly said to staff that she was dizzy, could feel bleeding and her limbs had gone numb.
Ms Hayes said Ms Seaman had been “begging staff to help her” and told them she did not want to die, but staff did not listen.
Ms Seaman had a covert intra-abdominal hemorrhage and was bleeding for hours, but she was incorrectly treated for possible dehydration and given biscuits, the court heard.
Crucially, notes about her health were annotated on a piece of paper which meant her deterioration was not escalated promptly.
The inquest found gross failures were made by multiple clinical staff across a number of disciplines, including the failure to follow the major hemorrhage protocol.
The new mother suffered two cardiac arrests and had been bleeding for hours. During emergency surgery, four to five litres of blood were found in her abdomen.
She died two days after giving birth following complications from the intra-abdominal hemorrhage.
Ms Hayes ruled there had been a failure of mandatory escalation before Ms Seaman died and said a prevention of future deaths report would be written.
She said had action been taken in the form of a review led by a multi-disciplinary consultant, Ms Seaman would not have died.
Ms Seaman’s family told the BBC: “We urge all those involved in Laura-Jane’s care to reflect on the failures in her treatment.
“Nothing gave her more joy than being a mum. That’s all she ever wanted to be and that’s what she did best.”
Maternity services at Broomfield Hospital were rated as “requires improvement” in the most recent inspection by the Care Quality Commission.
The hospital spokesperson said: “Our focus has been on improving training in recognising the early signs of deterioration and escalation routes in our maternity services to prevent this from happening again.”