The family of a woman who died of severe heart failure when pregnant with twins say it is ‘unforgiveable’ that a mistake led to the midwives and doctors treating her being unaware her family had a history of heart disease.
Kelly Forrest, 36, had lost her father when he was aged just 22 to cardiomyopathy – a hereditary disease of abnormal heart walls which is especially dangerous for pregnant women due to the added stress on the heart when having children.
Ms Forrest, who was already a mother of three children, had made midwives aware of her family history at her first antenatal appointment, where it was recorded in her medical notes, but due to a ‘memory lapse’ was not transferred onto Hull and East Yorkshire Hospitals NHS Trusts’ electronic systems.
Due to this error, Ms Forrest believed she was being cared for by midwives and doctors aware of her family background throughout her pregnancy, but that was not the case.
When 32 weeks pregnant, Ms Forrest’s family say she became increasingly unwell, suffering from breathlessness, sweating, feeling dizzy and vomiting.
She was sent home from Hull Royal Infirmary’s Maple Ward having been prescribed iron for anaemia, before being sent home again a day later from Priory Children’s Centre and advised to contact the antenatal day unit if her condition worsened.
However, just three days on June 5th, 2014, later Ms Forrest died after suffering severe heart failure and a massive loss of blood as doctors battled to save her when admitted to the emergency department in an ambulance.
Ms Forrest’s two baby boys survived having being delivered by a Caesarean Section, with one needing resuscitation.
Hospital staff only became aware she had she had died of dilated cardiomyopathy following a post mortem.
Investigation identified catalogue of errors pregnancy care
Now, following a legal case which consulted a number of independent medical specialists for expert opinion, Ms Forrest’s family have been told the catalogue of errors admitted by Hull and East Yorkshire Hospitals NHS Trust cannot categorically be attributed to her death.
Experts said her illness in the two and three days before her death was ‘unexplained’ and that her final illness was ‘complex, multifactorial and essentially untreatable.”
For her mother, Anne Campbell, this has been a difficult conclusion to accept, and she says such ‘basic errors’ being made in maternity units are a cause for wider concern.
“How on earth can something so significant simply not be entered into vital medical records when it is known to be dangerous to pregnant women?” she said.
“Kelly made it known to the doctors as soon as possible that there was the family history of losing her dad when he was just 22. They say it was a ‘memory lapse’ that led to that being missed during her care, but they may as well have just completely ignored her.
“It has been very difficult to accept that, despite the Trust admitting a string of errors in Kelly’s care, this error at the start- impacting on her entire care when pregnant – did not contribute to her death.
“My granddaughter (Kelly’s daughter), who is 21, is now having to go for regular testing in Leeds and the boys will do also. It is a serious condition and they want to monitor her closely and have said she must speak to them before trying for a baby herself.
“I am certain Kelly would have been monitored much more closely had it been known, they even admitted it should have been an ‘escalated matter’ during her pregnancy.
“The worrying thing is how many basic errors like this are being made across maternity care? What else should midwives and doctors be aware of when treating patients but are not? These kinds of mistakes are completely unforgivable.”
Root cause of incident was ‘memory lapse’
A Serious Incident Investigation concluded that the root cause of the incident had been ‘an unintended skill based memory lapse as the patients’ family history was not escalated appropriately or acted upon at any point during her pregnancy’.
As a result, details of the error have since been circulated across the NHS nationally. Hull and East Yorkshire Hospitals NHS Trust has also reminded all staff of the need to accurately transfer all hand-held records onto its electronic system, and that consultants and midwives must review handheld notes through the pregnancy.
Mrs Campbell added: “It is all very well saying lessons have been learned but how often do we hear that, and when such basic mistakes are being made, how can we believe it. You don’t need extra training to know the importance of making sure patient records have all vital details on.
“The only positive from this horrendous situation has been the two beautiful boys that were added to our family. They are three-years-old now and are starting to ask about their wonderful mummy.
“Kelly was a fantastic daughter and mother. She inspired her eldest daughter and cared for her middle son who has Aspergers Syndrome. She was very strong headed and wouldn’t hold back on her opinions and thoughts, so she’d expect us to speak out and highlight what happened.
“We tell the boys mummy is an angel and in heaven. She will certainly be looking down on them and she would have loved every minute of them.”
Nicola Evans, a medical negligence specialist at Hudgell Solicitors, has represented the family as they have demanded answers from the Trust.
She said: “This was a very sad incident and it is certainly fair to say there were many areas of concern with regards to the processes at Hull and East Yorkshire Hospitals NHS Trust and how basic errors were made which impacted on the future care of their patient.
“Ensuring midwives and doctors have all the relevant information at hand when caring for any patient, particularly a pregnant woman, is imperative and can be so dangerous if not the case.
“This case has led to lessons being learned at the Trust, which we certainly welcome, but also acts as a warning to other patients and mothers to not be afraid to repeat their concerns and ask questions of their care at all times. It is clear that doctors don’t always have all the information they need at hand to make the right calls, and that is a worry.”