A HOSPITAL missed repeated chances to save the life of an eight-months’ pregnant woman because she was never seen by a senior doctor, a sheriff has ruled.
Sheriff Daniel Scullion hit out at the “substandard care” given to Caroline McCall before her agonising death at one of Scotland’s leading maternity units.
Ms McCall, a 38-year-old social worker from Cambuslang, South Lanarkshire, was given the heartburn remedy Gaviscon when admitted to hospital with what she believed to be a heart attack.
She died clutching her chest almost two days later, having never been seen by a consultant obstetrician. Ms McCall suffered severe heart trauma.
Her premature baby was safely delivered by section 20 minutes after she finally collapsed.
Following a fatal accident inquiry at Glasgow Sheriff Court last summer, Sheriff Scullion has now ruled her death might have been avoided if she had been seen by an obstetrics consultant.
He said there were four opportunities for this: when she was first admitted to Glasgow’s Princess Royal Maternity Hospital on the morning of 24 November 2008; during the morning ward round or later that day; or when she was taken to the high-dependency unit on 25 November. She may have lived if she had been seen by a senior physician or if heart problems had been considered.
Sheriff Scullion also highlighted a “defect” in the hospital’s systems, which did not ensure an outstanding request for a review of an obstetric patient was highlighted as part of shift handover.
He said: “Caroline was admitted to a major maternity hospital because she was unwell.
“She died some 41 hours later, without a consultant obstetrician having seen her and without a consultant having been involved in any aspect of her treatment before the fatal collapse that immediately preceded her death.
“Indeed, no evidence was led to suggest that, prior to that collapse at 6:30am on 26 November 2008, any consultant was aware she was an inpatient.
“The lack of consultant obstetrician involvement clearly amounted to substandard care.”
The rare condition which killed Ms McCall, aortic dissection, a rupturing of the heart, went undetected and was only discovered post mortem. Cases of aortic dissection have increased in expectant mothers in the five years since her death.
Sheriff Scullion added: “Something needs done to improve the rate of detection of aortic dissection in expectant mothers.
“If it has not already done so, Greater Glasgow and Clyde Health Board should initiate discussion with the appropriate medical authorities, to ensure that the issue of improving the detection in expectant mothers of the life-threatening condition receives appropriate attention.”
The inquiry findings were welcomed by Alan Muir, 46, Ms McCall’s partner and father of her five-year-old daughter, Grace. He said: “The family’s position has always been that Caroline was not given a chance. That view has been borne out in the sheriff’s report.”
Mr Muir is suing the health board and wants them now to accept responsibility.
A spokesperson for the health board said: “The board would like to reiterate its deepest condolences to this patient’s family for their loss. We will examine the determination in detail.”