A Coroner has highlighted his concerns following the unexpected death of a new mum at Burnley General Hospital.
East Lancashire Coroner Mr Richard Taylor raised recommendations in the conclusion of an inquest into the death of building society manager Mrs Jane Whiteside (41) days after she gave birth.
These included the quality of statements provided by hospital staff, and that it had taken a death for East Lancashire Hospitals Trust to enact changes.
Mrs Whiteside, who suffered from the spinal condition scoliosis, had given birth by caesarean section without problems under general anaesthetic, and was due to go home when she was found unresponsive in a chair in her room.
There had been a gap of an hour in which Blackburn woman Mrs Whiteside was not seen by any clinical staff.
Recording a conclusion of natural causes, Mr Taylor said: “I am concerned at the quality of statements given by staff who attended to Mrs Whiteside as they do not tally. There is also concern that problems (in the maternity unit) also only came to light following her death.
“The discrepancies in the timings given in the statements at best confused the family and at worst made them suspicious.
“I will invite the Trust to invite me to talk about the quality of their statements.”
The Coroner did agree with the opinion of the eight staff who attempted resuscitation that Mrs Whiteside had already died by the time she was discovered.
He added: “I feel that all that could have been done had been done.”
Mr Taylor accepted the findings of pathologist Dr Richard Fitzmaurice who said Mrs Whiteside’s death was a cardiac arrest caused by sepsis, due to her scoliosis.
He discounted the opposing view of pathologist Professor Sebastian Lucas who said Mrs Whiteside had died as a result of Sudden Arrhythmia Death Syndrome (SADS).
The four-day inquest at Burnley Town Hall heard there had been no follow-up visit by the surgeon or anaesthetist as the surgeon was on leave and observations of her blood pressure and heart rate had been normal.
He added: “There was nothing to alert anyone to any significant problems. She was expected to be going home soon. I have come to the conclusion there was no specific failure from the hospital and am satisfied the Trust has made changes since this tragedy.”
Changes introduced include: one observation chart now used instead of two; a consultant leader introduced for the ward; post-operative checks now electronically recorded; and patient buzzers replaced so they can now be heard throughout the ward.
Mr Taylor added: “It’s clear Jane Whiteside was a much-loved mother, wife, daughter and friend to many.
“I have read glowing testimonials of her. In her children she will always be around. This has been a traumatic event for all who loved her.
“Her mother is understandably bemused as to how she could have lost her daughter at the same time as she gained a grandson.”
Speaking after the inquest, the family of Mrs Whiteside said they had grave concerns over the quality of care at the hospital given to “wonderful Jane”.
They added: “Follow-up visits were not conducted and the quality of reports and records were not accurate. Jane herself commented on the heavy workload of the midwives.”