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Inquest verdict

An Inquestconcluded yesterday into the death of a mother at Northwick Park Hospital, London.

Mrs Premalatha Jeevagan aged 27, died after giving birth to Photograph of Mrs Jeevaganher first child on the 18th May 2004.

The Inquest was held at Hornsey Coroner's Court North London by Dr William Dolman, HM Coroner for Northern District of Greater London. The Coroner said: "Mrs Premalatha Jeevagan died following concealed haemorrhage after a caesarean section. The gravity of her worsening condition, with increasing blood loss was not recognised and there was consequent delay in providing necessary treatment, which led to her death."

The family's solicitor Louise Forsyth of health specialists Alexander Harris said on behalf of the family:

"Mrs Jeevagan's family are happy with the verdict delivered by the Coroner.

They feel completely let down by the hospital and its medical staff who did not react quickly enough to the warning signs. The family raised concerns about Mrs Jeevagan's condition but even the concerns of her sister, who is a doctor, were ignored.

They are angry that the hospital did not contact the family after her death and it took a letter of complaint from the family before they did so.

They had to watch Mrs Jeevagan die and can't imagine how much she suffered. She was very scared and uncomfortable. Instead of celebrating the birth of their daughter Mr Jeevagan came home to organise his wife's funeral.

Mr Jeevagan will have to live with the loss of his wife for the rest of his life and one day he will have to explain to his daughter why her mother died.

The family wish to highlight their case, as what happened could have been so easily avoidable and they want to help to ensure changes are made at the hospital.

The family is currently pursuing legal action against the Trust who has admitted a breach of duty and accepts there were failures in the treatment of Mrs Jeevagan."

All media enquiries should be directed to the media management department at Alexander Harris on 08700 77 44 77.

Case Background:

Mr and Mrs Jeevagan, from Greenford Middlesex, were expecting their first baby. The estimated date of delivery was the first week in May 2004.

On 10th May Mrs Jeevagan attended Northwick Park Hospital after she woke up with swollen face and hands and had complained of reduced fetal movements. Her blood pressure was raised and due to the risk of pre-eclampsia she was admitted to hospital. Over the next 48 hours Mrs Jeevagan was not reviewed.

Three days after her admission it was noted in her medical records that her blood tests revealed low haemoglobin results and a blood transfusion was arranged and induction of labour recommended. Mrs Jeevagan was to be transferred to the delivery suite, however it was said to be too busy to deal with her.

On 16/17th May Mrs Jeevagan went into labour and at around 01.00 was transferred to the delivery suite. Labour progressed slowly during the day and a decision was made to deliver by caesarean section. This was conducted under general anaesthetic at 19.55 and a healthy baby girl delivered.

Following the caesarean, Mrs Jeevagan was under the care of a locum doctor as no senior obstetric medical staff were available. At around 21.30 her blood pressure began to drop and her heart rate increased. She was reviewed at about 22.00 by a locum registrar who made no note of any concerns. Fifteen minutes later Mrs Jeevagan's blood pressure was seriously low.

As her condition continued to deteriorate, the consultant obstetrician was contacted at home; he did not come to the hospital to take over care of Mrs Jeevagan. The locum was then called away to deal with another emergency, leaving no senior medical staff available to care for Mrs Jeevagan.

In the early hours of the 18th May 2004 Mrs Jeevagan went into cardiac arrest. The on call consultant arrived and Mrs Jeevagan was rushed to theatre where it was found that her uterus was filled with several litres of blood. Mrs Jeevagan sadly died on the operating table.

Hospital complaint

After her death, Mrs Jeevagan's family sent a letter of complaint to North West London Hospitals NHS Trust. The complaint was acted upon quickly and the Trust addressed most of the family's concerns.

The Trust completed an internal review report into Mrs Jeevagan's death, which concluded that there was a failure of care given to Mrs Jeevagan following the delivery of her baby as clinical signs of haemorrhage (falling blood pressure and rising pulse) were not adequately investigated.

The Trust has invited the Healthcare Commission, which has a statutory duty to assess the performance of healthcare organisations, to investigate the standard of maternity services provided at Northwick Park Hospital following a number of adverse events.

The inspection will establish whether the Trust is maintaining appropriate standards in the management, provision and quality of maternity care. It will cover antenatal care and delivery to ensure the safety, effectiveness, quality and appropriateness of maternity services.

Notes to Editor:

 

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