A busy labour ward and equipment problems preceded the death of a Northamptonshire woman following the caesarian birth of her twins.
A coroner found Sarah Dunlop, 35, from Towcester, died of a cardiac arrest at Northampton General Hospital on July 11, 2011, caused by huge levels of potassium in her blood that a succession of medical staff failed to act upon.
Dr Rina Panchal told the inquest she flagged up the abnormal levels to senior colleagues but that the labour ward was extrremely busy that day, delaying an order to perform an electrocardiogram (ECG) heart scan, which would have confirmed Mrs Dunlop was close to cardiac arrest.
Joanne Romecin, a senior midwife who repeatedly expressed her concerns, eventually carried out the ECG but two scanners failed and one had a flat battery. When a scan was completed, the printout could not be read and had to be repeated.
At points, Mrs Dunlop’s potassium levels were well above normal but doctors ordered retests because they thought they were so high it was an error. However, they admitted that prompt treatment instead of waiting for confirmation would not have harmed her. Her registrar, Mohamed Khalil, also admitted he was not aware how dangerous such a level of potassium in a pregnant woman was.
Senior doctors also conducted a routine handover of patients rather than see that the ECG was carried out as soon as possible.
Helen Mulholland, a solicitor for Mrs Dunlop’s family, said: “In a medical emergency a handover can wait.”
Dr Sonia Swart, medical director at NGH, said: “What should have been a joyful time for the Dunlop family was turned into tragedy with the death of Sarah after the birth of her twins.
“It will be of little consolation to the Dunlop family, but the events and circumstances that led to Sarah’s death are very rare. In the last five years NGH has cared for 25,000 mothers in our maternity unit; until this tragic case there had been no other deaths.”