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.