An inquest heard that staff at Northampton General Hospital failed to recognise the condition that killed a woman hours after the birth of her twins was a medical emergency.
Assistant deputy coroner for Northamptonshire, Tom Osborne, recorded a narrative verdict this morning at the inquest of Sarah Dunlop, aged 35, from Towcester.
The inquest, which started yesterday, heard that she died of a cardiac arrest nine hours after a caesarean section, which was caused by hyperkalemia, extreme levels of potassium, and pre-eclampsia, which means kidney damage, on July 11, 2011.
Signs of her conditions included high potassium and protein levels, and these were spotted in blood tests as early as June and continued to be brought up in tests both before her caesarean section and in the hours after the births of her twins.
Mr Osborne said: “There was a failure on the part of clinical staff to recognise the serious nature of her condition that resulted in a failure to take the necessary steps to treat her condition.”
Dr Owen Cooper, a consultant obstetrician and gynaecologist, who led the team regarding the investigation into the serious incident report, said in his evidence that the recommendations made in the report has been accepted by NGH.
He said it was more than likely that Mrs Dunlop would have survived if the seriousness of her condition had been recognised.
However he said although he agreed to an extent that a haemorrhage that was discovered after the postmortem played a role, he didn’t think it was the main cause of her death.
In a statement released after the inquest, Dr Sonia Swart, medical director at Northampton General Hospital NHS Trust, 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. We offer our deepest sympathies to Sarah’s family and we are very sorry for the failings in the care that were identified by our own investigation and have been confirmed by the inquest. The Trust fully accepts the Coroner’s verdict.
“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.
“We are confident that our maternity service is fit for purpose and one that our local community can rely on but we are not complacent about our services.
“We have undertaken a full investigation into what happened in this case and made a series of changes as a result. We have also asked the Royal College of Obstetricians and Gynaecologists to review our unit and its processes. We remain committed to constant improvement in quality.”
Mrs Dunlop, who was born in Northampton, worked as an account manager and was married to Christopher Dunlop, aged 34.