A new mother's death just weeks after she gave birth to her son could have been prevented if it had not been for "serious failings" by the medical staff caring for her.
This is the ruling of South London coroner Dr Roy Palmer who recorded a narrative verdict into the death of Malgorzata Doniec at Croydon Coroner’s Court yesterday (January 21).
The 43-year-old, of Essex Grove, Upper Norwood, died from bleeding on the brain on November 3, 2010, after suffering from a severe headache for several weeks.
This came about due to a complication with the first epidural injection administered during her labour, where the needle used to administer the anaesthetic punctured the dural membrane at the base of the spine, causing cerebrospinal fluid to leak into the epidural space.
This problem, known as a dural tap, caused her to suffer agonisingly painful headaches as fluid built up in her skull.
But note-keeping errors meant the causes of her symptoms were missed by GPs and midwives in the weeks after the birth.
And further problems meant when she was admitted to hospital in the days before her death there were failings in her care, the inquest at Croydon Coroner’s Court was told.
When Miss Doniec was admitted to accident and emergency on October 30 a junior doctor suspected the headaches were due to intercranial pressure.
But this doctor was not aware there had been a dural tap and as a junior doctor out of hours at the A&E she was not able to order a CT scan.
'Failures of a serious kind'
Further problems in her treatment meant a CT scan was not ordered until around 24 hours later after Miss Doniec had collapsed.
Dr Palmer said: "There were several failures of a serious kind that resulted in lost opportunities to treat Miss Doniec, who was recognised from an early stage as having raised intercranial pressure.
"I do think it probable that had Miss Doniec undergone a scan during the early hours of Saturday 30th October she would have been referred to St George's sooner and I consider it probable she would have survived."
He added: “My very sincerest condolences to Miss Doniec’s partner and her family in Poland and I’m very sorry that her son will never know his mother but I have no doubt his family will tell her all about her in due course.”
Croydon Health Service NHS Trust has introduced safeguards and changed policies at the hospital as a result of Miss Doniec’s death.
These include a red flag system where a red sticker is placed on the front of a patient’s notes if they have had a dural tap during labour.
A CT scan can now be ordered by the A&E staff at any time.
And pregnant women, and those who have given birth within the past 28 days, now have consultations jointly with consultants from the obstetrics department and A&E staff.
What improvements has the hospital made to its patient care?
In a statement the trust’s medical director Steve Ebbs said: “This is an extremely sad case which has led to significant changes in how we organise and coordinate care for women during pregnancy and for mothers who have recently given birth.
“We took swift action following this case in 2010, to investigate what had gone wrong.
“We invited external experts to look at what happened, the quality of our care and how this was provided.
“We have since made significant changes to our emergency department, acute medical unit and the process for patients being discharged from hospital.
“Women who have a dural tap are now monitored more closely in hospital and more information about this procedure is shared with them, community nurses and their GP.
“These are important changes but we know none of this will change what has happened for Miss Doniec’s family and for this, we would like to express our deepest sympathies.”