"Missed opportunities" to save Woodley mum's lifeBy Laura Herbert
September 17, 2012
There were ‘missed opportunities’ to save a mother who bled to death hours after giving birth, a coroner ruled.
Claire Teague and her husband Simon hired independent midwife Rosemary Kacary, known as Rosie, to support them through their second pregnancy.
Mrs Teague, 29, previously lost one of their twins during a Caesarean section at Royal Berkshire Hospital (RBH), in Reading, in June 2009, the coroner’s court at Windsor Guildhall heard.
The couple, of Elmwood Close, Woodley, planned to have the baby at North Hampshire Hospital in Basingstoke but decided to opt for a home birth on the advice of the midwife, Mr Teague claimed.
Following the birth in the early hours of August 1, 2010, Mrs Teague fell ill and was later taken to RBH where doctors found one third of her placenta had not been removed, which led to a haemorrhage.
She was rushed to theatre but died later that day.
Mr Teague told the inquest last Wednesday: “Rosie pulled the cord six or seven times, it was aggressive. The placenta came out with a lot of force and tugging.
“She was using a small torch to inspect the placenta. There may have been a lamp on but it was a dark environment.”
Ms Kacary refuted this, saying: “I could never and would never inflict that kind of violence on anyone.
“There was no doubt in my mind it [the placenta] was complete.”
Dr Helen Allott, consultant obstetrician at RBH, told the inquest the outcome may have been different if Mrs Teague was taken to hospital earlier.
She said: “Had the placenta been examined in good light it would have been apparent a large piece was missing. I have looked at thousands of placentas and I was quite shocked by this.”
Dr Allott added it was high risk for Mrs Teague to give birth at home due to high blood loss during her first labour and possible scar rupturing.
The inquest heard Ms Kacary left the couple’s home at around 10am but returned a few hours later after Mr Teague sent a text message to say his wife was asking for an ambulance to be called.
Ms Kacary said: “It suggested to me there couldn’t have been anything serious as he was happy to persevere for another hour.
“All I know is if I asked my husband to call me an ambulance he would do it. Simon knows his wife better than I do.
“Claire had a normal pregnancy, she had a really lovely normal spontaneous birth at home and I hope in time, Simon will remember that.”
The inquest heard Ms Kacary had previously been investigated by the Nursing and Midwifery Council but there were no sanctions on her practice.
Berkshire coroner Peter Bedford recorded a narrative verdict stating there were ‘missed opportunities’ to take Mrs Teague to hospital earlier.
He noted the inspection of the placenta was carried out in ‘very poor light’ and referred to text messages and calls between Mr Teague and Ms Kacary.
He said: “They gave cause to a missed opportunity to explain the extent of Claire’s deteriorating condition and maybe an ambulance could have been called earlier.
“It is not possible from the evidence to conclude whether CPR or earlier intervention might have affected the outcome, but I think it is important to note it is recognised many mothers suffer from retained placentas but deaths from such a cause are rare because they occur in a hospital setting.”
He added: “This has been difficult and emotional for everyone involved. I think everyone involved is a victim and one’s heart goes to the family.”
Speaking after the hearing, Mrs Teague’s dad James Pragnall said: “The coroner fairly summarised and noted there was a missed opportunity to do things, but I am disappointed he couldn’t go as far as to say that my daughter’s death was contributed to by the negligence of the midwife.”