EXCLUSIVE: Labour ward where mum-of-five bled to death run by junior doctor and colleague in first week on the job

A labour ward, where a mum of five died, was being run by a junior doctor with a newly-qualified colleague in their first week on the job, it has emerged.

Staff in charge on the night Laura-Jane Seaman pleaded with medics to "not let her die" also included a junior anaesthetist and they all had "limited experience of working on a labour ward", a coroner has revealed.  

Laura-Jane, 36, had a history of haemorrhages, which the hospital trust was aware of, but despite her cries for help after she suffered another one, medics caring for her missed it for hours, even when she lost consciousness.

She had been admitted to Broomfield Hospital, Chelmsford, on December 20 2022, to give birth to her latest child.

The birth itself was uneventful, but she suffered post labour complications.

Sonia Hayes, area coroner for Essex, who presided over the inquest held in August, has now blasted Mid and South Essex NHS Trust, which runs the hospital, over a string of failings.

She has published a prevention of future deaths report, in which she highlighted that the trust's own probe had missed a catalogue of failings and problems with the experience on the ward.

She wrote: "Staff skill mix for doctors on the Labour Ward for the night of 20/21 December was staffed with a junior obstetric registrar with a newly qualified colleague in his first week and a junior anaesthetist, all with limited experience of working on the Labour Ward.  

The trust carried out an 'acute 72-hour investigation' into what went wrong, but she said it failed to identify many of the failings and the outcome was not shared with the trust's director of midwifery or the hospital's head of midwifery.

Failings he highlighted included an "absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage," a "lack of compliance with national guidance and training" and "Significant omissions in the medical record-keeping".

Her report said "some medications administered were entered into a medication chart from a previous admission."

It added that there was a lack of compliance with triggering a major haemorrhage protocol, there was no contemporaneous labour ward medication chart and poor communication and information sharing between staff.

Vital signs for patients on the labour ward were also being annotated on a piece of cardiotocography paper in the absence of the required charts, she added.

The report said: "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 a consultant obstetric review, 2222 alert, or referral to the critical care outreach team.  

"The maternal collapse was categorised as a “faint” by trust staff and Laura-Jane was treated for potential dehydration and administered medication that had only a transient effect.  

"There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised."

Worryingly, she said that The Trust Executive Review Group (“ERG”) report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital, who subsequently did not agree with all of its conclusions.

She said the report had claimed that "‘the absence of escalation to an obstetric consultant was discussed" and it was noted that "the team escalated it to an anaesthetist, which is usual practice."

The report also said that "the possible reasons why the bleeding was not identified were discussed" and it went on to note "that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration."

However, those more senior at the trust had later disputed these findings.

Key information "was omitted in handovers between staff at all levels including when Laura-Jane was taken to theatre as a medical emergency," her report said.  

She added: "Therapeutic anticoagulation was administered without consultant obstetric input... "No accounts were taken from haematology, or the blood lab team involved with this massive haemorrhage by the Trust or the HSIB (who investigated this case) where  massive amounts of blood products were prepared, dispensed and then administered  where the timings and sharing of information were important to understand.    

Her report called on the trust to introduce changes to prevent a repeat.

She added: "In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

The trust has until February 7 to send a response.

Due to the unnoticed bleeding, at around 6.30am on December 21, Laura-Jane went into cardiac arrest, resulting in her undergoing four surgeries, requiring multiple blood transfusions.

However, she did not recover and died on December 23.

The family are represented by law firm Leigh Day in a clinical negligence claim.  

In a statement following the inquest, her family, who said the "beautiful mum lit up the room," said: “We urge all those involved in Laura-Jane's care to reflect on the failures in her treatment and we hope that Mid and South Essex NHS Foundation Trust will take strong and swift action to ensure that these failures are never made again."

Diane Sarkar, Chief Nursing and Quality Officer for Mid and South Essex NHS Foundation Trust, said: “We extend our sincerest sympathies and condolences to the family of Laura-Jane. Her tragic death has affected us all at the Trust greatly. Following investigations into the circumstances that led to her death, our focus has been on improving training in recognising the early signs of deterioration and escalation routes in our maternity services to prevent this from happening again.”

The trust added it would meet the deadline for response.