AN inquest found several blunders by hospital staff led to the death of a mum just days after she gave birth to twin boys.
Hartlepool Magistrates’ Court clerk Joanne Hatton died after her condition had “spiralled out of control” after she gave birth to twins Ben and Miles on December 30, 2008, an inquest heard.
Among a list of failings, the inquest heard Mrs Hatton, 38, lost two litres of blood during the Caesarean section operation and, despite a doctor ordering her to be given a blood transfusion, it was not done two hours later when he returned to her bedside at Darlington Memorial Hospital.
Mrs Hatton, from Darlington, who was also mum of daughter Amelia, six, was sent to the hospital’s high dependency unit, rather than the intensive care ward, because of a shortage of beds.
And despite suffering kidney failure and liver problems, no-one linked her deterioration with the blood loss, her husband, Julian, told the hearing.
Three days after giving birth a consultant said her kidneys had recovered and she would be transferred back onto a general ward a few days later. But doctors then became concerned about problems with her liver.
She was later transferred to the Royal Victoria Infirmary, in Newcastle, where a specialist neurological team worked to reduce pressure that had built up on her brain and she died on January 20.
Last week, only days before the coroner’s hearing, County Durham and Darlington NHS Foundation Trust accepted responsibility for the tragedy.
Newcastle Coroner David Mitford ruled that treatment for her complications led to her untimely death.
Mr Hatton, 44, said afterwards: “To learn the full extent of the mistakes that were made, and which led to Joanne’s death, was incredibly difficult. It has forced us to revisit a nightmarish time when I and my family were helpless as Joanne’s condition deteriorated from one of good health into a virtually comatose state in a matter of a few days.
“Jo is missed more than words can say and nothing can compensate for her loss as a wife and mother to our children. I know I speak for my wife’s many friends and the whole family, especially Joanne’s parents, Neil and Barbara, and her brother David, when I say that we sincerely hope lessons have been learnt from the errors that were made.”
Mr Mitford gave a narrative verdict, saying: “Joanne Hatton died in the Newcastle General Hospital on January 20, 2009, as a result of multi-organ failure.
“She had given birth to twins by Caesarean section on December 30, 2008, at Darlington Memorial Hospital following which she suffered significant postpartum haemorrhage which was followed by kidney and liver failure.
“She was transferred to Newcastle upon Tyne on January 4, 2009, suffering from hepatic encephalopathy, coagulopathy and HELLP syndrome. She suffered intracerebral haemorrhage as a result of necessary treatment for those conditions.
“Medical management at Darlington Memorial Hospital of her post partum haemorrhage, subsequent hypothermia and possible hypovolaemia together with a lack of medical and midwifery communication contributed to her subsequent medical complications which ultimately led to her death.”
County Durham and Darlington NHS Foundation Trust said: “The trust also wishes to apologise for the fact that Joanne did not receive the high standard of care that she was entitled to expect following the birth of her twins.
“The circumstances of Joanne’s management have been investigated thoroughly by the Trust and as a consequence, changes have been made to the way that obstetric patients who suffer from post-partum haemorrhages are now managed.”
The trust added in a letter sent to the family that it hoped to reach a financial settlement soon.