New mother died after transfer delay

What happened

When Mrs D was pregnant with her first child, she went to the GP Practice with nosebleeds. She had two episodes of bleeding during her pregnancy.

After she had given birth at the Trust, Mrs D's condition deteriorated. Trust staff cared for Mrs D on a general ward and did not transfer her to the coronary care unit until her condition got worse. Clinicians diagnosed her with abnormal blood vessel development in her lungs and other complications. Doctors suggested that Mrs D should be referred to a specialist unit at another trust, but clinicians at the first Trust took another six days to contact the specialist unit at the second Trust.

At the second Trust, Mrs D continued to deteriorate. Seven days after her transfer to the second Trust, she had a cardiac arrest. Attempts at resuscitation were unsuccessful and she died.

Mrs D's family raised complaints about the GP Practice and the first and second Trusts. Each organisation gave a number of responses to their complaint. However, Mrs D's sister was dissatisfied with the responses and complained to us.

What we found

We partly upheld this complaint. The GPs at the Practice responded correctly to Mrs D's symptoms.

Mrs D's antenatal care at the first Trust was reasonable and in line with established good practice. There was no evidence that the Trust missed an underlying medical condition at this time.

We also considered the care Mrs D received from the first Trust after the birth of her child, when her condition deteriorated. Nursing staff did not recognise that Mrs D needed more frequent observations or identify that she needed a medical review. We found, however, that more frequent observations at this point would not have altered the final outcome for Mrs D.

Nevertheless, as the Trust failed to recognise these failings, we were not satisfied that it had taken appropriate action to ensure the same things would not happen again.

The cardiology and respiratory teams should have got consultant support earlier. If this had happened, Mrs D might have been referred and transferred to the specialist unit at the second Trust more quickly. However, Mrs D's condition was severe and progressive. We did not find that more or earlier consultant involvement would have affected the final outcome.

There were failings in communication between doctors at the first Trust, and these may have delayed Mrs D's referral to the second Trust. Doctors at the first Trust also delayed contacting staff at the second Trust to discuss Mrs D's transfer. We thought that these delays had little effect on Mrs D's illness.

There were no failings in the care Mrs D received at the second Trust.

Putting it right

We recommended that the first Trust apologise to Mrs D's family for the failings we had identified. We also recommended that it prepare an action plan to describe how it would make sure it learnt from the failings identified by this complaint.