A mum tragically died only hours after she gave birth to her firstborn son after a midwife and doctor’s “mistakes” led to her uterus being turned inside out.
“Kind and caring” Jade Hart had only just given birth to baby Hugo after 10pm on July 8, 2018 at Bassetlaw Hospital in Worksop, Nottinghamshire.
However in the early hours of the following morning she suffered a rare complication called a uterine inversion, where the uterus turns inside out, and died as a result.
This happened because of a number of mistakes carried out by one of her doctors and a midwife at the hospital, an inquest at Nottingham Coroner’s Court concluded.
Jade’s heartbroken mum, Julie Hazelgrave, said after the inquest: “Jade was wonderfully kind and caring with a great zest for life.
“In July 2018, with her husband, Jade walked into Bassetlaw hospital full of excitement and anticipation for the birth of their baby.
“Jade had a perfect life and marriage and, when their son was born, I saw that Jade was the happiest she had ever been.
“Cruelly, all happiness was short-lived when, within one hour of birth, Jade collapsed and died in the immediate hours thereafter. We remain devastated at the loss of Jade.
“Her death has cast a long shadow over our lives and our world has irrevocably changed. We miss Jade every single day and always will.”
The 33-year-old’s umbilical cord was yanked at least four times by a doctor when her placenta had not been separated, the inquest said.
This action led to Mrs Hart’s death and was branded a “very serious omission of care” according to Assistant Coroner Dr Elizabeth Didcock.
The new mum also suffered a number of cardiac arrests but would not have died were it not for the uterine inversion, the inquest found.
It also found that the mismanagement of her ongoing haemorrhage contributed to her death as regular checks were not undertaken in the hours before she passed.
Mrs Hart lost at least 5.5 litres of blood the inquest said and eventually experienced organ failure and brain damage. Neglect contributed to her death.
The individual mistakes could not have been foreseen by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, the inquest said. They came instead as a result of guidance not being followed.
The trust did come under fire from the coroner for report passed on by them to medical bodies after the incident.
It omitted criticism and analysis done by an independent expert on the incident.
The expert who undertook the review found that Jade’s doctor had breached their duty of care and their actions were “well below” what was expected of them.
They continued it was a “truly exceptionally bad” decision that would result in a massive risk of death.
On top of that, they said mismanagement of Mrs Hart’s haemorrhage also represented a gross breach of duty.
Jade's husband Richard Hart said: “Being independent and thorough, Jade's inquest has been invaluable to our understanding of what happened to Jade, that turned what should have been a wholly wonderful day into one with tragedy.
“Ascertaining the facts is important, not least for our son who now has to live his life without his mummy.”
He added: “It is time to find some peace and time to grieve the gift that was Jade, while concentrating on the joy and gift that Jade gave to us, our beautiful son.”
Mr Hart was in the room with his wife and baby Hugo the whole time before she fell seriously ill.
He said he had no recollection of her being asked to push, or making sounds to suggest she was pushing, despite what was initially suggested by her doctor.
Prior to giving birth, Mrs Hart asked for an epidural which was rejected over fears of her high blood pressure.
The inquest found this request should have been granted and would have given her some relief from the pain.
Meanwhile, a failure to control her blood pressure was found to not likely have contributed to her death.
Dr Didcock criticised the hospital’s trust for a report written after the incident.
In it, she said it did not include any recommendations or analysis from the expert who provided the independent review.
Dr Didcock told the inquest: “Serious omissions has led to insufficient learning and no acceptance that this had caused serious distress to the family.
“This poses a risk of similar deaths occurring in the future. I am not reassured the necessary actions are in place.”
She told the family: “I'm so sorry for your loss. It's also my hope that lessons will be learned that will lead to improvements in care going forward.”
The final cause of death for Mrs Hart was given as brain injury, multiple cardiac arrests and uterine inversion from inappropriate management during third stage labour.
Dr Tim Noble, Executive Medical Director at Doncaster and Bassetlaw Teaching Hospitals (DBTH), said: “On behalf of the Trust, I want to again share my sincere apologies and sympathies with Jade’s husband Ric and her family and friends.
"As was highlighted during the inquest, this was a truly tragic case and we are grateful for the Coroner’s time and careful deliberation in reaching a conclusion.
"We will review carefully the Coroner’s findings and take any actions needed to further improve the safety of the Trust’s Maternity services.”
