Manchester Conference Centre. Wednesday 30 th April & Thursday 1 st May 03.

4th Annual Multidisciplinary MeetingRisk Management & Medico-Legal Issues in Women's Healthcare. Manchester Conference Centre. Wednesday 30th April & Thursday 1st May 03.

Grainne Barton Partner Clinical Negligence Alexander Harris Solicitors CLAIMANT HEALTH LAW SPECIALISTS LONDON – NORTH WEST – WEST MIDLANDS

Chronology of Events 6/2/99 – 7/2/99 Time • 22.24 & 22.25 Twins Delivered. Uneventful caesarean section and pregnancy • 23.00 Back to postnatal ward. In a single room. B.P on transfer 120/70 on summary of labour. Laura complaining of headaches on arrival (recorded in cardex.) Continued on next slide

Chronology of Events 6/2/99 – 7/2/99 • 01.35 1ST B.P reading 190/100 when care taken over by another midwife. Pulse 64. • 01.40 RMO Visited Complaint severe throbbing headache.

TOUCHE “asked to see patient complaining of Severe throbbing headaches + blood pressure 190/100. Sudden onset. Temples, no flashing lights/visual disturbances. No epigastric discomfort through wound. • Discomfort on arrival Co-Dydramol given for headache. On examination – in distress. Urine protein trace. Continued on next slide

TOUCHE • Blood pressure 200/100, reflexes – left = right, not excessively brisk. No clonus, abdomen tender. No epigastric tenderness. Impression – elevated blood pressure? secondary to pre-eclamptic toxaemia or secondary to headache. • Plan: 1 – analgesia, 2 – anti-hypertensive medication, 3 – accurate fluid balance, 4 – quarter hourly observations, 5 – pre – eclamptic toxaemia bloods”

Chronology of Events Time • 02.40 Nifedipine given One to one nursing care instituted. • 03.00 Discussed with anaesthetist • 03.30 Reviewed by Dr Kean Blood patch undertaken Continued on next slide

Chronology Of Events • 04.10 Blood test results Renal and hepatic dysfunction • 04.20 Slurred speech • 05.00 Reviewed by Obstetrician. Transfer to Middlesex Hospital

CT scan confirmed a right intracerebral bleed Transferred to National Hospital of Neurology 15th of February 1999 – Laura pronounced brain dead Post mortem undertaken at family’s request not the Coroners. Revealed no aneurysm or arteriovenous malformation.

CORONERS ACT 1988s.8.3(d) (8.3)If it appears to a coroner, either before he proceeds to hold an inquest or in the course of an inquest begun without a jury, that there is a reason to suspect – (d)that the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health and safety of the public or any section of the public he shall proceed to summon a jury in the manner required by subsection (2) above.

CORONERS ACT 1988S.8(1) (8.1) Where a coroner is informed that the body of a person (“the deceased”) is lying within the district and there is reasonable cause to suspect that the deceased - • has died a violent or unnatural death; • has died a sudden death of which the cause is unknown; or • Has died in prison or in such a place or in such circumstances as to require an inquest under any other act, then, whether the cause of death arose within his district or not, the coroner shall as soon as practicable hold an inquest into the death of the deceased either with or without a jury

REGINA v POPLAR CORONER, Ex parte THOMAS (1992), WLR 26.03.93 p547 • A 17 year old girl died following a severe attack of asthma. An ambulance had been called shortly after 1am, but it did not arrive until after 1:30am. There was medical evidence that suggested that her life would have been saved had she arrived at the hospital earlier. • Coroner refused to hold inquest on basis that the deceased had not died an “unnatural death” within the meaning of s.8(1)(a) of the Coroners Act 1988 • The deceased’s mother made an application for judicial review of the coroner’s decision.

JUDICIAL REVIEW Judicial Review allows people with a sufficient interest in a decision or action by a public body to ask a judge to review the lawfulness of: • An enactment; or • A decision, act or failure to act in relation to the exercise of a public function.

Table 3.3 Causes of death to eclampsia and pre-eclampsia; United Kingdom 1985-99

TOUCHE

CORONERS ACT 1988S.15 (15.1) Where a coroner has reason to believe – • that a death has occurred in or near his district in such circumstances • that owing to the destruction of the body by fire or otherwise, or to the fact that the body is lying in a place from which it cannot be recovered, an inquest cannot be held except in pursuance of this section, he may report the facts to the Secretary of State. (15.2)Where a report is made under subsection (1) above, the Secretary of State may, if he considers it desirable to do so, direct a coroner (whether the coroner making the the report or another) to hold an inquest into the death.

Foreword – Jervis By the Rt. Hon. Lord Justice Simon Brown Over these years, so far from the pace of developments slackening in this area of our law, it has if anything quickened. …… partly too, I have no doubt, it results from what many feel to be the increasingly important role played by the Coroner’s Court in modern society. …… there has never been greater need than in these explosive days to ensure that tragic fatalities are investigated thoroughly and independently and brought speedily before a court of law. That essentially is what the Coroner’s Court exists to do. And doing it goes a long way towards controlling high-running emotions and assuaging public anxieties. October 1993

JERVIS ON CORONERS In the second case a 31 year-old woman gave birth to twins by caesarean section under spinal anaesthetic. Although measured after delivery, her blood pressure was not then measured for 2½ hour period, by which time she had severe hypertension, leading to cerebral haemorrhage. She suffered a left-sided hemi-plegia, and died 8 days later. The medical evidence suggested that, had her blood pressure been monitored in the immediate post-operative phase, her death would probably have been avoided. Continued on next slide

JERVIS ON CORONERS Her widower sought an inquest, which the coroner refused on the grounds that his wife’s death was not “unnatural”. The husband applied to the High Court for an order requiring the coroner to hold an inquest, and succeeded. The coroner appealed. The Court of Appeal held that the evidence in this case was such that the coroner could not properly decide otherwise than that there was reasonable cause to suspect that the death was at least contributed to by “neglect” (in the technical non-negligence, sense) and hence unnatural. But the court also seemingly adopted the view that the notion of “unnatural death” encompassed any death, albeit from unnatural causes, which was wholly unexpected and resulted from a culpable failure. This decision represents the current view of the higher judiciary upon the subject.

HOW TO AVOID LITIGATION • Communication with staff and patients. • Thorough recordings of investigations and thought process. • Learning from mistakes and correcting systems where they have failed. • Early senior involvement if warranted. • Review of staffing levels on “danger days.” • Encouraging incident reporting. • Hold your hands up – apologise

Manchester Conference Centre. Wednesday 30 th April & Thursday 1 st May 03.