RHIAN EMMA KATE ROSE · Prevention of Future Deaths report

On 3 December 2019 an investigation was commenced into the death of Rhian Emma Kate Rose. The investigation concluded at the end of the inquest hearing on 21 October 2021 at Redditch Coroner’s Court, in the Worcestershire Coroner Area. The conclusion (a ‘narrative’ conclusion in Box 4 of the Record of Inquest) was that Ms Rose’s death was owing to ‘medical complications following feticide.’

Rhian Rose was 28 weeks pregnant when she underwent genetic testing which discovered trisomy 21. At 31 weeks Rhian underwent feticide (on 22 November 2019 at the Birmingham Women’s Hospital) and attended, as planned, the maternity unit of Worcestershire Royal Hospital (run by Worcestershire Acute Hospitals NHS Trust (WAHT)) for the second phase of medical termination of pregnancy on 24 November 2019.

Rhian’s became unwell during her stay in hospital, as evidenced by observations taken between the evening of 24 November 2019 and the afternoon of 25 November 2019. The management plan was for Rhian to progress in labour and deliver vaginally, however Rhian’s condition significantly deteriorated in the early evening on 25 November 2019. This resulted in unconsciousness, an emergency caesarean section and hysterectomy, with Rhian later going into cardiac arrest. Despite significant efforts at resuscitation and a number of returns of spontaneous circulation, Rhian could not be saved, and she died in the evening on 25 November 2019 at the Worcestershire Royal Hospital.

A post-mortem examination revealed the following cause of death:

1a – multi organ failure
1b – sepsis
1c – feticide for trisomy 21

Box 3 of the Record of Inquest (which answered how, when and where Rhian came by her death) read as follows:

‘Rhian Rose underwent feticide on 22 November 2019 and was admitted to a maternity ward on 24 November 2019 for medical termination of pregnancy. By the evening of her admission, Rhian had clear symptoms of infection, however these were sepsis pathway and antibiotics were not commenced until the following morning. Full consideration was not given as to whether an elective caesarean section would be the optimal mode of delivery to attempt infection source control. In the late afternoon on 25 November 2019 Rhian became acutely unwell resulting in unconsciousness, emergency caesarean section and subsequent cardiac arrest. Despite lengthy attempt at resuscitation, Rhian died at 21:06 hours on 25 November 2019 at the Worcestershire Royal Hospital.’

1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery. This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options. I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans.

2) Infection risk of retained foetus following feticide – I am concerned that a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical discussions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. Cases such as Rhian’s may well be rare, however consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide.