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Woman died after midwife failings - coroner


An expectant mother bled to death after a private midwife failed to spot 30% of her placenta was still inside her, a coroner has ruled.

Claire Teague, 29, hired independent midwife Rosie Kacary when she became pregnant for the second time after she lost one of her twins during an emergency caesarean section in 2009.

The young mother, of Woodley, near Reading, gave birth to a baby boy in the early hours of August 1 2010, but began to feel unwell, complained of being in pain and started bleeding heavily, Windsor Coroner’s Court was told.

She was rushed to hospital by ambulance where doctors found a third of her placenta had not been removed, causing a massive haemorrhage.

She died soon afterwards.

At the conclusion of a two-day inquest into her death, Berkshire Coroner Peter Bedford said it was “difficult to avoid” evidence given by expert midwives that it would have been obvious the placenta was not whole.

He said the decision to deliver the placenta in a darkened room with the curtains closed was likely to be behind the fatal error.

“The inspection of the placenta was conducted in poor quality and the manner of the inspection was such that she did not appreciate that approximately a third had been retained,” he said.

“I find it difficult to avoid the evidence of the experts involved who conclude that it was very obvious that there was a significant portion of the placenta missing.

“The only logical explanation I can come to is because the lighting cannot have been adequate.”

Recording a narrative verdict, the coroner also said there were “missed opportunities” to take Mrs Teague to hospital sooner, both by the failure to spot a serious tear and the failure to realise she was seriously unwell when she asked her husband to call an ambulance.




Readers' comments (6)

  • As Midwives we are trained to assess the placenta thoroughly for missing lobes and ragged membranes. the most important factor here is where the uterus contracted regardless of the retained products.
    uncontrolled bleeding is an early sign of retain products and a uterus that did contract.
    Again after delivery a key symptoms from an eexpectant mother is when she says that she is not feeling well. this is a red flag that a midwife should always be on the alert for.
    So i cant really say what happened here.
    Poor lightinging is not an excuse, visible continous bleeding is sign that something is wrong so early intervention could have been carried out.

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  • michael stone

    Anonymous | 7-Sep-2012 3:02 pm

    Latterday Midwife wrote much the same, in the other NT post about this same case - why has NT put the same story up, under two slightly different banners ?

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  • Florence

    From reading back over the first story I think NT has put the story up again as the first story was reported on before the Coroners findings were completed.

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  • Its really shocking to see the attitude of midwives.My personal experience one month back has taught me that midwives really don't care about the way the person feels.In my case no PV examination was not done eventhough I requested the midwives to do and finally when the PV examination was done it was found to be fully dilated and I was being rushed to the labour room and so staff there also did not get enough time to prepare themselves.Sometimes its the casual attitude of the people which can put others life into danger and appropriate actions should be taken in such incidences because no-one can bring one person back to life if something goes wrong.

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  • Midwives are specialists in normal pregnancy. We are trained to recognise high risk pregnancies, complications and their appropriate management. The pregnancy in this case is clearly high risk!
    Placenta should always be checked for completeness whether the lighting was sufficient or not - this is a midwife's duty to do so for the safety of our clients! Midwives should listen to the complaints/ concerns of our clients esp for a woman who had phobia of hospital to have requested an ambulance should ring a bell.

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  • I respect and admire all the hard work that midwives do and also the very specialised training that they they undertake. Most midwives are compassionate and professional in their delivery of care;however as in any profession there are always those that slip through the net.
    I have had 2 children, 18 years apart and can say both experiences have been very different. The first was tantamount to assault you were shaved, given an enema and kept in hospital for a week regardless of your own needs and wishes. I was treated like a piece of meat on a slab, but that was how it was before we entered the brave new world of education and compassion. Hence the reason why I didn't have anymore children for many years. The second (and by this time I was a trained nurse) was, in contrast entirely different. I went in fully prepared with a birth plan and a clear idea of how I wanted my birth experience to be. Unfortunately the midwife that delivered me was 'old school' and after a very easy birth, she wanted to 'just put a few sutures' to close a very minor tear. Fortunately I had the confidence to say no. My permission was not sought and possible complications and outcomes were not discussed. The young midwife that was with her said to me afterwards - "good for you standing up for yourself". I am now healed and perfectly well. There is a lot to be said for the academic side of nursing and midwifery. It gives you insight and knowledge to underpin and consolidate the learning experience. Pity it doesn't change arrogance and inherent personality.

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