Missed opportunities to change the course of events before death of young Black mother, inquest concludes

Assistant Coroner Dr Liliane Field concluded Ayaan Waeys died of a brain haemorrhage caused by high blood pressure with pre-eclampsia, the separation of the placenta from the uterine wall and a clotting disorder and that sub-standard care meant she was left waiting four and a half hours for an intensive care bed.

The coroner indicated she will also consider issuing a Prevention of Future Deaths report in due course. 

Ayaan died on 16 November 2022 at St Thomas’ Hospital in London, 14 days after the stillbirth of her first child, a girl, two months before her due date. 

A seven-day inquest into Ayaan’s death was held in September at London Inner South Coroners Court, concluding Tuesday 7 October. 

The inquest heard that on 1 November 2022, Ayaan attended the maternity assessment unit (MAU) at St Thomas’ Hospital for a routine appointment. The only midwife on duty recorded a raised Protein Creatinine Ratio (PCR) result of 38, taken four days earlier, which diagnosed pre-eclampsia. 

According to the trust’s guidelines, a result at that level required escalation to a consultant obstetrician. However, no consultant review took place. Instead, the midwife had a brief conversation with a registrar between caesarean sections but told the inquest she could not recall what had been said.  

Believing the result may have been a false positive, the inquest heard the midwife repeated the PCR test but sent Ayaan home before the result became available. In fact, it was significantly raised at 198, but this was not seen by the staff in the MAU. If it had been, admission would have been arranged. 

The inquest was told on 2 November, Ayaan returned to hospital in labour at 36 weeks. By this time her baby had already died, most likely due to a placental abruption. Ayaan went on to suffer a catastrophic brain haemorrhage following excessive bleeding estimated over 2.5 litres, and was placed into a coma, and died two weeks later. 

Expert evidence from consultant obstetrician Dr Edward Mullins concluded that Ayaan should have been admitted on 1 November for close inpatient monitoring including four-hourly blood pressure checks and twice daily CTG scans. Had this taken place, changes in her blood pressure or foetal movements could have been detected earlier, providing opportunities to manage her pre-eclampsia and prevent the fatal cascade of events. He told the court that the failure to admit Ayaan on 1 November “caused or contributed to her death”. 

The inquest also heard evidence from other clinicians that, had the consultant team been alerted of the PCR result, they would have admitted Ayaan and carried out further investigations on 1 November. 

Ayaan’s family, who live in Kings Cross, are represented by Firdous Ibrahim, medical negligence solicitor at law firm Leigh Day.   

Ayaan’s family said: 

“Ayaan was a much-loved wife, daughter, sister, and friend whose warmth, kindness, and generosity touched everyone who knew her. Losing both her and baby Nuseiba has been devastating for our family, and we continue to feel the deep pain of their absence every day. 

“We are grateful that the inquest has carefully examined what happened and has recognised that there were missed opportunities to protect Ayaan and her baby. While nothing can ease the heartbreak of our loss, we hope that the coroner’s findings and the considerations into a potential Prevention of Future Deaths report will lead to meaningful change in maternity care. Our wish is that lessons are learned so that no other family has to endure the same tragedy.” 

Firdous Ibrahim said: 

“On behalf of Ayaan’s family, we welcome the coroner’s findings that there were tangible missed opportunities to change the course of events before Ayaan died. This tragic case highlights how crucial it is that clinical guidelines are followed and that appropriate escalation takes place when there are signs of serious risk to mother and baby. 

“From the evidence heard, there was a lack of obstetric-led care and continuity in the clinical management of Ayaan’s pregnancy from the outset. This is particularly concerning given that Ayaan exhibited multiple high-risk factors, including gestational diabetes and persistently uncontrolled hypertension (more common in minority groups), which warranted consultant obstetric led care and intervention, but instead Ayaan’s care was midwifery led. 

“Ayaan’s family have shown remarkable strength and dignity throughout this inquest, despite the tragic loss of two lives. They now hope that lessons are learned from what happened, so that no other family has to experience the profound loss they have endured. 

A government report recently published by the health and social care committee found Black women in England face disproportionately poor outcomes in maternity care. It said this was shaped by systemic failings in leadership, training, data collection and accountability.    

Firdous added: 

“While statistics on Black maternal mortality are often cited, this case is a stark and painful example of the human cost behind those numbers. It highlights the urgent need for meaningful change, not just in policy but in practice, to ensure that Black women receive the safe, respectful, and equitable care they deserve.”