A mother of twins died shortly after giving birth via Caesarean
section after hospital staff failed to carry out a doctor's
instruction to give her an urgent blood transfusion.
The hospital trust has admitted a series of medical errors which
led to Joanne Hatton’s death at an inquest into her death.
Mrs Hatton, 38, who had worked as a legal
adviser at Hartlepool magistrates’ court, Cleveland, lost two
litres of blood during the Caesarean section, the inquest
heard.
Dr Ahmed Ali, who at the time was the
gynaecological clinical lead at Darlington Memorial Hospital, said
he ordered a blood transfusion but when he returned two hours later
he found it had still not been done.
The inquest was also told that Mrs Hatton,
of Darlington, County Durham, was sent to the hospital’s high
dependency unit, rather than the intensive care ward, because of a
shortage of beds.
Despite suffering kidney failure and liver
problems, no one linked her deterioration with the blood loss, her
husband, Julian, told the inquest.
In a statement which was read to Newcastle coroners’ court, Mr
Hatton, 44, said the doctors and midwives dealing with his wife at
Darlington Memorial Hospital did not communicate properly and added
that medical staff gave the impression that no one person was in
charge of her care.
He said the hospital had underestimated his wife’s blood loss
after she haemorrhaged heavily after the birth of her twins, Ben
and Miles, on December 30, 2008.
Mr Hatton said: “It was just like a domino effect. Joanne’s
condition spiralled out of control after the delivery of the babies
and nothing could be done to prevent her deteriorating
condition.”
He added: “Joanne’s condition deteriorated and nobody appeared
to link that deterioration with the significant amount of blood
that she lost in theatre and when she was being tended to by the
midwives.
“First it was believed she had kidney problems and that these
were separate problems not linked to her blood loss. Then the same
happened when next it was determined that she had liver
problems.
"Again, it was like nobody linked her deterioration with her
significant blood loss. Nobody appeared to be talking to each
other.’’
The County Durham and Darlington NHS Foundation Trust said it
had made a number of improvements to the high dependency unit and
intensive care services, and had also reviewed the way specialists
interact with each other across departments.