2 June 2008
A narrative verdict was handed down on 30th May 2008 by Her Majesty’s Coroner, Andrew Walker, at Hornsey Coroner’s Court into the death of Ana Maria Denzo, the tenth maternal death at Northwick Park Hospital between April 2002 and March 2005.
Ana Maria died on 19 March 2005, age 30 years, after giving birth to her first child, on 23 February 2005, by caesarean section. Her labour had been slow to progress and, although the baby had been identified as disproportionately large and therefore Ana Maria was at risk of being unable to deliver vaginally, she was allowed to carry on labouring without making the expected progress. Midwifery and medical staff failed to monitor and review the effect of Syntocinon which was being given to augment contractions, with the result that her uterus became overstimulated, triggering a postpartum haemorrhage soon after the delivery of the baby.
In the attempt to stop the bleeding, Ana Maria underwent a hysterectomy. Her initial blood loss was estimated at 10 litres but later revised to 15 litres (an adult has about 3 litres of circulating blood, so blood loss of this magnitude is severe and necessarily includes loss of transfused blood). At some stage during the hysterectomy the inferior vena cava (large blood vessel) was damaged, necessitating the removal of a perfectly healthy kidney and an ovary in the scramble to repair the inferior vena cava and stop the bleeding when the resulting internal haemorrhage was finally recognised the following day; but, by this time, Ana Maria had developed a persistent coagulation (blood clotting) problem. She remained in ITU on a ventilator until her death on 19 March.
The Coroner’s verdict reads: Ana Maria Denzo was admitted to hospital for the delivery of her baby on the 23rd February 2005. Mrs. Denzo’s death was contributed to by neglect, as the delivery of her baby would have taken place when the use of oxytocin had produced hyper contraction of the uterus without any progression of her labour. In reality the period of uterine hyper contraction went unnoticed until 12.30. At 16.05 the baby was delivered, the uterus became atonic and massive post partum haemorrhage resulted. A hysterectomy was performed during which time an injury was caused to the inferior vena cava. Mrs. Denzo was taken to the high dependency unit following the surgery. From 10.30 in the evening there were ongoing failures in the care of Mrs. Denzo which represented a lost opportunity to treat the haemorrhage from the injured vessel. Mrs. Denzo passed away despite continued medical treatment on 19th March 2005.
The family are grateful to the Coroner for the opportunity to have seen and heard members of the midwifery and clinical staff responsible for Ana Marie’s care admit to the failings that led to her tragic death. They are deeply concerned to have heard news that three more women have died recently in the same unit and can only hope that lessons will have been learnt by the Trust which will go some way to ensuring the mistakes made in Ana Marie’s case are not repeated.
Leigh Day & Co represent the families of two of the women who died at Northwick Park Hospital. For further details please contact Sarah Campbell
on 020 7650 1200.
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