13 Dec 2024 LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Omission of covert bleeding from the Trust Drills & Skills Booklet View source Failure to recognise covert bleeding causing hypovolaemia View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Mid and South Essex NHS Foundation Trust Royal College of Obstetricians and Gynaecologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Mid and South Essex NHS Foundation Trust
Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
View source
Royal College of Obstetricians and Gynaecologists
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
View source
Royal College of Obstetricians and Gynaecologists
Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
View source
Mid and South Essex NHS Foundation Trust
Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
View source
Mid and South Essex NHS Foundation Trust
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
View source See 2 more actions
×
AI-generated summary
LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Omission of covert bleeding from the Trust Drills & Skills Booklet
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet .
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team.
” Source location LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise covert bleeding causing hypovolaemia
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised . The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet .
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team.
” Source location LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
Verbatim wording from the response “7) An ‘unwell woman’s’ simulation based on antepartum and postpartum haemorrhage including uterine rupture, abruption, and Vasa Previa, as well as a separate simulation on an anaphylaxis scenario was included in the 2023 PROMPT maternity training for all staff in addition to Human factors training, teamwork, situational awareness, and escalation.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Verbatim wording from the response “The RCOG’s clinical guidance in this context includes the following:” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
Verbatim wording from the response “2. Maternal Collapse in Pregnancy and the Puerperium⁴ (Green-top Guideline No. 56). Clearly states that: “An obstetric modified early warning score chart should be used for all women undergoing” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
Verbatim wording from the response “Since August 2024, the maternity unit at Broomfield hospital has begun the implementation of a new obstetric bleeding strategy. The strategy works alongside current PROMPT recommendations of managing a postpartum haemorrhage already in place at the maternity unit.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Verbatim wording from the response “The service identified these issues in the initial review of the incident. Since Laura-Jane’s death there has been an implementation of a new MEWS package with escalation policy. This includes the trigger response/medical emergency team once a score of 7 or above is reached.” Source location Response from Mid & South Essex NHS Trust
Open published response
13 Dec 2021 Mrs Hurrun Maksur · Prevention of Future Deaths report East London
View report summary
Concerns raised 2
Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected View source Lack of specific training for obstetricians to identify intra-abdominal bleeding View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Resuscitation Council UK Royal College of Obstetricians and Gynaecologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Resuscitation Council UK
Emphasise ultrasound use during advanced life support to identify reversible causes, including haemorrhage, across cardiac-arrest guidance.
View source
Resuscitation Council UK
Include pregnancy-specific guidance to identify and treat reversible causes, with focused ultrasound available for skilled operators.
View source
Resuscitation Council UK
Include guidance on abdominal ultrasound and massive-haemorrhage protocols for suspected haemorrhage during pregnancy-related cardiac arrest.
View source
Royal College of Obstetricians and Gynaecologists
Discuss with emergency-medicine and radiology educators the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.
View source
Resuscitation Council UK
Consider additional learning from the case and review relevant guidance and teaching materials for necessary updates.
View source
Resuscitation Council UK
Share the response with the Advanced Life Support Group overseeing the Managing Medical and Obstetric Emergencies and Trauma course.
View source
Royal College of Obstetricians and Gynaecologists
Require early-pregnancy ultrasound practitioners to screen for ectopic pregnancy.
View source See 4 more actions
×
AI-generated summary
Mrs Hurrun Maksur · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hurrun Maksur, who was 19 weeks pregnant, suffered a seizure and cardiac arrest after developing severe abdominal pain on 6 June 2020. She was treated for suspected pulmonary embolism, but an intra-abdominal bleed from a ruptured interstitial ectopic pregnancy was subsequently discovered; she died during further surgery on 7 June 2020. Concerns included the failure to perform a FAST scan before thrombolysis, the absence of the guidance from national obstetric cardiac arrest guidance, and specific training for obstetricians to identify intra-abdominal bleeding.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” Source location Mrs Hurrun Maksur · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific training for obstetricians to identify intra-abdominal bleeding
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” Source location Mrs Hurrun Maksur · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emphasise ultrasound use during advanced life support to identify reversible causes, including haemorrhage, across cardiac-arrest guidance.
Verbatim wording from the response “1. The RCUK updates its guidelines on a regular basis using a process that is accredited by the National Institute for Health and Care Excellence (NICE). The most recent update was in May 2021. With regards to the use of sonography (ultrasound is the more commonly used term), the latest 2021 RCUK guidelines include:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include pregnancy-specific guidance to identify and treat reversible causes, with focused ultrasound available for skilled operators.
Verbatim wording from the response “b. Specific guidelines for cardiac arrest in the pregnant patient including 'Identify and treat reversible causes (e.g. haemorrhage). Focused ultrasound by a skilled operator can be used to identify reversible causes and may also be used to assess if a fetal heart rate is present.' See https://www.resus.org.uk/library/2021-resuscitation-guidelines/special-circumstances-guidelines” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include guidance on abdominal ultrasound and massive-haemorrhage protocols for suspected haemorrhage during pregnancy-related cardiac arrest.
Verbatim wording from the response “2. The RCUK Advanced Life Support Manual (8th Edition, May 2021) includes the following regarding haemorrhage:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with emergency-medicine and radiology educators the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.
Verbatim wording from the response “It is our intention to engage in discussions with educators from the Faculty of Emergency Medicine and the Royal College of Radiologists to reinforce the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.” Source location 2021-0418-Response-from-RCOG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider additional learning from the case and review relevant guidance and teaching materials for necessary updates.
Verbatim wording from the response “5. To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the need to exclude major bleeding as the cause of collapse before giving thrombolytic drugs for suspected PE in pregnancy. We will also consider other learning from this case. The following areas will be reviewed and updated as necessary:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the response with the Advanced Life Support Group overseeing the Managing Medical and Obstetric Emergencies and Trauma course.
Verbatim wording from the response “5. To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the need to exclude major bleeding as the cause of collapse before giving thrombolytic drugs for suspected PE in pregnancy. We will also consider other learning from this case. The following areas will be reviewed and updated as necessary:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require early-pregnancy ultrasound practitioners to screen for ectopic pregnancy.
Verbatim wording from the response “Screening for ectopic pregnancy is a mandatory part of the ultrasound assessment in early pregnancy. Anyone undertaking a scan in early pregnancy must check for a potential ectopic pregnancy. This is specifically stated in our advice regarding ultrasound training: ultrasound-scan-guidance-vfinal.pdf (rcog.org.uk)” Source location 2021-0418-Response-from-RCOG_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing RCUK guidance and teaching materials already address ultrasound use and reversible causes, including haemorrhage, during cardiac arrest in pregnancy.
Verbatim wording from the response “4. The RCUK ALS subcommittee's opinion is that the issues raised by the MBRRACE report and the Inquest are addressed in the most recent RCUK guidance and teaching materials. Specifically:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Universal ultrasound requirements are limited because skilled operators and equipment may be unavailable and ultrasound could delay time-critical treatment.
Verbatim wording from the response “a. Firstly, RCUK is mindful that its guidelines address all cardiac arrests and that maternal cardiac arrests make up a very small proportion of these arrests. In addition the specialist skills and equipment required for ultrasound during resuscitation are not always immediately available in all settings. Any changes therefore need to be proportionate and recognise the risks of delaying time critical treatments such as fibrinolysis in patients with a suspected PE.” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is not feasible to train all obstetric doctors to reliably perform FAST scans because routine opportunities and opportunities to maintain competence are insufficient.
Verbatim wording from the response “In A&E, abdominal scanning is usually performed by doctors working within the A&E department who are trained to look for intra-abdominal bleeding; for example in cases of abdominal trauma, ruptured arterial aneurysms etc. It is very rare indeed for an obstetric doctor to be carrying out such a scan within an A&E department and most obstetric doctors would go through their whole hospital career without being asked to perform an ultrasound in these circumstances. Because of the lack of opportunities within routine O&G clinical practice, it would not be feasible to train all our doctors to be able to do this reliably even using simulation. Not only would it be difficult to organise training, they would not be able to retain their skills by regular practice - unlike doctors working in A&E.” Source location 2021-0418-Response-from-RCOG_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.