Samantha Beach · Prevention of Future Deaths report

On the 21st June 2013 the Acting Coroner for Gloucestershire commenced an investigation into the death of Samantha Beach. The inquest was formally opened on the 25th June 2013, and I held a pre inquest review on the 26th June 2014 (having been appointed as Senior Coroner for Gloucestershire on the 1st June 2014). The investigation concluded at the end of the inquest on the 8th-9th October 2015. The conclusion of the inquest was a narrative conclusion. The medical cause of death was ruptured splenic artery aneurysm.

Sam was a healthy 25 year old young lady. She had given birth to two babies previously without any problems. On the 10th June 2013 she developed severe chest pain within three hours of giving birth to her third child. She also developed intermittent tachycardia. Her pain persisted when she was discharged from hospital on the 12th June 2013. Whilst she was in hospital her severe chest pain was not investigated appropriately. Sam made midwives and junior doctors aware of her pain. Advice was not sought from more senior colleagues. Between the 13th – 15th June her chest pain continued and she was seen at home by community midwives and an out of hours GP. Sam was not readmitted to hospital. On the 17th June she attended the emergency department with ongoing chest pain, but she was discharged again within three hours. Advice from an obstetrician was not sought. On the 20th June 2013 she had further severe chest pain, she fitted and then she collapsed. Whilst she was being transferred to hospital she had a cardiac arrest. She was admitted to hospital in a state of cardiac arrest. Cardio-pulmonary resuscitation was carried out. The clinicians considered the most likely diagnosis to be pulmonary embolism, and therefore Sam was anticoagulated. However it soon became apparent that her abdomen was swelling, and intra-abdominal bleeding was suspected. An emergency laparotomy was carried out, and it was found that she had bleeding from a ruptured splenic artery aneurysm. A splenectomy was carried out. Postoperatively her condition deteriorated. The clinicians could not stabilize her coagulation. She suffered a further cardiac arrest on the 21st June 2013. She was pronounced deceased at 06.58 hours. If her severe chest pain had been adequately investigated it is more probable than not that her splenic artery aneurysm would have been detected. If detected, it is more probable than not that Sam could have undergone successful operative repair.

(1) The clinical care provided to Sam in the obstetric department was not escalated appropriately to more senior colleagues,

(2) When Sam was being cared for in the community, there was no process to ensure the sharing of information or joining up of care between the midwives, out of hours, GP and obstetric department.

(3) When Sam attended the Emergency Department as a post-natal patient (7 days post partum) the obstetric department were not involved in her care.