A hospital “missed opportunities” to save a young mum who died just weeks after giving birth, an inquest was told
Bethany Katie Barker, 20, collapsed at the home of her partner’s parents less than a month after having an emergency caesarean.
She was then rushed back to hospital where she was tragically pronounced dead on August 29, 2018.
The causes of death were later given as pulmonary embolism and pulmonary infarction, an inquest heard.
It was said that Ms Barker had been given blood thinner Tinzaparin to reduce the risk of her developing a blood clot following the birth on August 6.
But a mix-up at University Hospital of North Tees meant she was given the wrong dose, Teesside Live reports.
Teesside Coroner’s Court, sitting at Teesside Magistrates’ Court, was told that the hospital also failed to identify that she was suffering from a blood clot – a pulmonary embolism.
Her partner Callum Blair told the court, during his evidence, that there were no signs that Bethany’s health was deteriorating after she was discharged.
He said that he did not know she was suffering from chest and lower leg pain until she told the health visitor on August 17.
The court heard how Bethany, from Thornaby, was readmitted to hospital with a suspected blood clot and doctors diagnosed her with pneumonia.
Callum’s mother Lisa Blair told the court how the couple stayed at her home after Bethany was discharged from hospital for a second time on August 23.
She told the court that Bethany did not appear to be struggling with her breathing or feeling sick.
However Bethany’s aunt, Gillian Cox told the court how she was in regular contract with her while she was on holiday in Cyprus.
She told the court: “She said she felt tired. Then on 17th she phoned me quite panicked saying she was getting pains in her chest, struggling to sit back and pain in her calf and she was breathless.
“I came off the phone and I thought I think she had a clot.
“I said was the midwife coming and she said she was due anytime. I said speak to her straight away.”
Gillian told the hearing that Bethany told her that she had been given antibiotics after being diagnosed with pneumonia.
She said the day before her death Bethany, who was brought up by all of her immediate family, had told her aunt she was unwell with sick or blood in her mouth every time she lifted her head up.
She said that Bethany wasn’t someone who wanted to “cause trouble in anyway” and if she had been there she would have rang the doctor for her.
Bethany’s cousin Linda Cox added: “She doesn’t like to cause any issue. If she was in pain she would keep it to herself as long as she could.”
The inquest heard how on August 29, 2018 Lisa found Bethany face down on the floor and rang 999 for help.
Dr Helen Simpson, a consultant obstetrician from James Cook University Hospital in Middlesbrough, was asked to look at the case by the coroner’s court.
She found that Bethany had been discharged by the University Hospital of North Tees with an “inadequate” dose of tinzaparin.
Dr Deepak Dwarakanath, Consultant Gastroenterologist at the University Hospital of North Tees, told the court in his evidence: “By not giving the full dose then we wouldn’t have reduced the risk as much as we should have.”
When Coroner Claire Bailey asked him if he thought it would have contributed to the risk of a pulmonary embolism, he replied “yes”.
Consultant Obstetrician Stephen Wild told the court how a junior doctor had prescribed the incorrect amount of tinzaparin and another doctor, who realised there was an error, prescribed the correct dose.
He said that this led to two prescriptions being sent to the ward and Bethany’s midwife discharging her from the hospital with the incorrect dose.
Mr Wild told the court how extra checks were now in place so there won’t be more than one prescription sent to the ward and no error can be made.
Coroner Claire Bailey told the court that she agreed with the medical cause of death outlined in the post-mortem examination – pulmonary embolism and pulmonary infarction.
She said the University Hospital of North Tees had accepted Dr Simpson’s findings and so did she.
Coroner Bailey said she also accepted the evidence that the failings to exclude the pulmonary embolism did, on the basis on probability, contribute to Bethany’s death.
She gave a narrative verdict in which she told the court: “Bethany gave birth at University Hospital of North Tees on 6 August 2018.
“She died at University Hospital of North Tees on 29th August 2018 following recent complications following child birth.
“Her death was contributed to by missed opportunities to prevent, identify and treat a pulmonary embolism.”
Ms Bailey added that she was “satisfied” that the hospital trust had taken the case seriously and had put steps in place to prevent more deaths from occurring in this way.
A hospital trust spokesman said after the hearing: “North Tees and Hartlepool NHS Foundation Trust unreservedly apologises for the failings in care that led to Bethany’s death.
“We immediately introduced improved procedures to ensure this will not happen again.
“Our thoughts are with the family.”