Sunday, 20 March 2016

"Systematic failings" kill a pregnant woman at St. Peter's Hospital.

Every so often I get the feeling that I should have stopped this Blog long ago and just got over what St. Peter's did to me and got a life.

Then something like this story comes along and I realise that I should have done a lot more than I did.....that I should have fought much harder to get someone to listen to me.

This story is from 'Get Surrey' and it reports the Coroners comments on a totally unnecessary death caused by St. Peter's absolute negligence in dealing with a pregnant women.

If it wasn't enough that she was misdiagnosed from the beginning, they then decided that she wasn't ill and didn't let her see a consultant for 40 hours.

When her mother tried to remove her from St. Peter's Hospital to another hospital their response was to security!!

It's an absolute disgrace - actually it's manslaughter.

See if I'm wrong;


"Systematic and individual failings at St Peter's Hospital led to death of  pregnant woman".

08:00, 19 Mar 2016
By Matt Strudwick
Get Surrey

Rhianne Barton died just two days after doctors wrongfully diagnosed her with gastroenteritis in February last year

Coroner: Lost possibilities to intervene which "could have and should have" changed the course of events
"Systematic and individual failings" in the treatment at St Peter’s Hospital of a heavily pregnant woman who died from complications following surgery have been highlighted by a coroner.

Rhianne Barton, from Ashford, died on February 13 2015 at the Chertsey hospital, when an operation to treat an internal hernia caused fluid to flood her lungs.

This happened two days after doctors had wrongfully diagnosed her with gastroenteritis.

The 27-year-old, who was 35 weeks pregnant with her first child, had been admitted onto the labour ward on February 10 with "excruciating" stomach pains and persistent vomiting, before being transferred to the antenatal ward the next

Woking Coroner’s Court heard on Wednesday (March 16) how doctors showed a lack of consideration of gastric bypass surgery the legal assistant had had at St Mary’s Hospital in December 2013.

Assistant coroner Dr Karen Henderson said the "closed minds" and a mistaken belief by doctors and midwives that she was not significantly unwell led to a "lack of urgency" to consider any other diagnoses.

She said: “I find as good medical practice this should have been considered and excluded independently of how well she looked.”

The inquest heard how a consultant, present during a ward run on the morning of February 11, was not asked to see Miss Barton as it was not a "done thing".

“It’s not rocket science that if someone is admitted in the previous afternoon they deserve to be seen by a consultant who has the responsibility for care and delivery of that care,” said Dr Henderson.

It was more than 40 hours until Miss Barton was assessed by a consultant, a delay Dr Henderson said was "critical".

Mum had 'every right' to be unhappy; Dorothy Osuji had searched her daughter’s symptoms on Google after "getting no help" from medical staff where she correctly found her condition to be "fatal".

“Mrs Osuji had every right to be deeply unhappy about the care her daughter had,” said Dr Henderson.

“Mrs Osuji did as much as humanly possible to obtain best care for her daughter, but was not believed and active steps were not taken to reassure Rhianne or her mother. They gave, in fact, false assurances that actions were being taken.”

Dr Henderson said the medical team’s response to call security upon hearing Mrs Osuji had arranged to transfer her daughter to St Mary’s Hospital was "absolutely unacceptable".

On February 12 an ultrasound and MRI scan confirmed Miss Barton had a small bowel obstruction. She was rushed into surgery for an emergency caesarean at 6pm to deliver her
daughter, who survived.

But fluid rushed up and flooded Miss Barton’s lungs, blocking her airwaves. Surgeons waited until she was stable to carry out further surgery, but she suffered a fatal cardiac arrest.

The inquest heard there had been a number of lost possibilities to intervene which "could have and should have" changed the course of events.

“This was due to individual and systematic failures in the care Rhianne was given,” said Dr Henderson. “They were in turn directly causative of Rhianne’s death. But for this failure
Rhianne would not have died in the way she did.”

Recording a narrative conclusion, Dr Henderson, visibly emotional, said: “Without doubt it’s a tragedy to the hospital, but a particular tragedy not only to Rhianne’s family who have lost a daughter, but her daughter has lost a mother
and my absolute condolences for that.”

Dr Henderson said she would be writing a Prevention of Further Deaths report to Ashford and St Peter’s Hospitals NHS Foundation Trust requiring it to respond outlining what action will be taken.

In a statement, the trust’s chief nurse, Heather Caudle, said it fully accepted the coroner’s conclusion.

She said the trust has since changed the way it manages high-risk pregnant women to ensure consultants review their care daily, as well as looking at improving communication between its teams.

“We know many of these things will be of little comfort to Rhianne’s family as they come to terms with their grief and the responsibility of bringing up Rhianne’s beautiful daughter,” she said.

“We are truly sorry for their loss and if and when Rhianne’s family would like, we wish to work closely with them to keep them informed of the improvements and changes we have made.”


Incidently, Robyn tells me that following a Gastric Bypass, American good practise would be for pregnant women to see a specialist Gastro Enterologist at the beginning of pregnancy to chart out how complications like this can be avoided.

Which indicates that a stomach hernia is not unusual in these circumstances.

In the year since this completely unnecessary death - who has been held responsible?

No one.

Neil Harris
(a don't stop till you drop production)
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