Mum died giving birth to twins after ‘medics gave life-saving fluids to the wrong patient’
Despite Estelle O'Sullivan being declared a "high risk" patient, essential operating instruments were allegedly missing from the theatre
A MUM died giving birth to twins after a series of hospital blunders, an inquest heard today.
Estelle O'Sullivan died from a cardiac arrest after losing three litres of blood following the Caesarian operation to deliver her babies.
An inquest heard that a midwife was forced to run for help when an emergency button in the operating theatre did not work.
It was also found that medics had written down the wrong type of blood on the patient's records and specialist fluids ordered to be delivered to the hospital were given to the wrong patient.
Essential operating instruments were allegedly missing from the theatre.
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That was despite the 37-year-old being declared "high risk" because of a previous "pregnancy problem" and Caesarian section with her last child.
She suffered from a blood disorder which meant doctors at Wexham Park Hospital in Slough, Berks., planned for her to have the same operation for the birth of her twins.
She had been admitted to hospital throughout her pregnancy with heart palpitations and dizziness - but the day before her death, her waters broke and she was admitted to the maternity ward.
Ms O'Sullivan, who lived in Neptune Way, Slough, Berks., had lost half a litre of blood by 11am on the day of her death at Wexham Park Hospital but reported feeling well and feeling her twin boys moving inside her.
However, hours later she began to feel surges of severe pain in her stomach and when the babies' heart rates were hard to monitor, the situation was escalated to an emergency and an ultrasound examination was carried out, raising alarm over the health of the babies.
The twins were born just before 3pm on February 24 and were rushed to the Special Care Baby Unit but their mother suffered a cardiac arrest on the operating table - and when a midwife pressed the emergency call button, it did not work and she had to run to the labour unit to call for help.
Midwife Tiffany Gurbishley told the inquest that 775ml of blood had been lost over a 24-hour period when Ms O'Sullivan reached the operating theatre.
"Estelle was taken to the operating theatre with an estimated blood loss of 775ml and put in the care of Mr Wagley (consultant)," she said.
"I scrubbed up to receive twin two and I remained in the theatre until both babies were in the Special Care Baby Unit.
"The anaesthesist made us aware that Estelle had a cardiac arrest and I ran to the labour unit as the bell had failed.
"The purpose of the emergency buzzer is to get extra hands there. Mr Wagley carried out CPR."
Ms O'Sullivan was treated as a high risk patient as she was carrying twins and had had a C-section before, and her waters had broken pre-labour making both her and the babies vulnerable to infection, the inquest in Reading, Berks., was told.
Consultant anaesthetist Dr Suraj Jayasundera said plans had been put in place for the operation to be carried out on Thursday, February 26, as an 'elective' C-section but a search was made for a time slot for one sooner.
"At 6pm I spoke to transfusion. They had no platelets but could send them by blue light from Oxford," he said.
"Platelets help blood clot. They are needed to be in significant numbers to help blood clot."
Coroner Mr Bedford said: "There is a reference here to the possibility Estelle received the wrong blood."
Dr Jayasundera said he did not know about a mix-up in blood types and a scan for placenta accreta, a life-threatening condition where the placenta attaches to the uterine wall, revealed Ms O'Sullivan "was not known to have the condition".
775ml of blood had been lost over a 24-hour period when Ms O'Sullivan reached the operating theatre
Tiffany Gurbishley
He told the coroner's court: "A number of scans were done and she was known to be a high-risk patient. I explained to Estelle that if she bled again she might have to be given general anaesthetic and be moved. More than one bag of platelets was needed.
"We agreed to try to get it done the next day. I think they were a bit concerned about an emergency happening at the same time."
Due to foetal distress, a Category One - the most urgent - C-section was carried out and the babies were delivered just before 4pm.
An hour later Ms O'Sullivan suffered a cardiac arrest but apart from the emergency call button not working, a defibrillator was found to be low on battery and it was discovered there were no platelets at the hospital and that the units of blood were low although nine units were eventually transfused.
A legal representative for Ms O'Sullivan's family then asked: "Do you have any idea why, when the platelets were ordered for Ms O'Sullivan, they were used for another patient?"
The senior anaesthetist did not know.
Dr Ndubueze Anyaegbuna treated Ms O'Sullivan on the day of her death and stayed with her in the Intensive Care Unit where a decision was made to stop resuscitating her.
Mr Bedford said: "The suggestion in the report is that morbidly adherent placenta was recognised but not documented. Was the significant blood loss underestimated?"
Dr Anyaegbuna told him: "I don't think the severe blood loss was underestimated. You have to cut the anterior placenta to deliver the baby. She had lost nearly a litre of blood."
Mr Bedford said a report revealed the volume of haemorrhage was underestimated at the time the cardiac arrest and meant staff did not adequately respond with blood products.
However, the consultant told him the presence of pulmonary oedema - fluid in the lungs - suggested this was not the case but said Ms O'Sullivan haemorrhaged quickly and staff tried to understand what could have caused the cardiac arrest, including considering septicaemia or anaphylactic shock.
Prior to the cardiac arrest everything was going as it should have done.
Mr Bedford
He said prior to the cardiac arrest everything was going as it should have done.
The coroner said estimated blood loss in the haemorrhage was three litres but that a report criticised communication between staff about the blood loss before and after the operation, making the severity of the situation unclear.
Dr Anyaegbuna was questioned by the family representative and said he did not know about the placenta accreta which Ms O'Sullivan suffered.
The legal representative asked if he knew about a plan to X-ray her to confirm whether she had placenta accreta and also questioned why post-partum haemorrhage was not included in the anaesthetist's list of what could have caused the cardiac arrest.
"Your statement is that what was thought of but you have not listed haemorrhage as what should be thought of," she said.
Dr Anyaegbuna said: "If it was haemorrhage she would not have had the pulmonary oedema she was having."
He said medics became aware of the fluid in Ms O'Sullivan's lungs during the process of resuscitation.
The inquest continues.
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