Rachael Walker

On 9 August 2022 I commenced an investigation into the death of Rachael Chloe WALKER aged
36. The investigation concluded at the end of the inquest on 3 March 2023. Article 2 of the European Convention on Human Rights was engaged due to the relevance to Chloe’s death of hospital Trust policies and systems. The conclusion of the inquest was: -

Chloe died of the effects of placental haemorrhage and amniotic fluid embolism at week thirty-seven of her pregnancy due to diagnosed placenta praevia. It is probable that her death would have been avoided if a delivery plan made for her had been recorded in her notes and acted upon, and if the relevant Trust had incorporated national guidance issued in September 2018 which provided for consideration for earlier caesarean delivery.

Rachael Walker, known as Chloe, died in hospital on 19 June 2021 due to experiencing a placental haemorrhage and amniotic fluid embolism at the thirty seventh week of her pregnancy. Chloe had been diagnosed with placenta previa during her antenatal care.

Chloe had antepartum haemorrhage at home on the early morning of 19 June 2021 and had to be taken to hospital by ambulance. At the maternity unit she experienced further haemorrhage and was taken for emergency caesarean section. Her baby was delivered but Chloe quickly went into the first of three cardiac arrests. On the evidence it is not apparent that there was a postpartum haemorrhage, but she did develop blood clotting disorder and disseminated bleeding, likely related to the placental haemorrhage and amniotic fluid embolism. Chloe sadly died in the operating theatre despite prolonged resuscitation attempts.

Chloe had recognised risk factors in her pregnancy and the consultant obstetrician with lead responsibility for her care decided at an appointment at week thirty-four of Chloe’s pregnancy on a plan to review Chloe at an appointment at week thirty-seven, with a view to offering hospital admission and planned caesarean section by week thirty-eight due to the placenta previa. That plan was not recorded in Chloe’s notes with the result that the obstetric registrar who saw Chloe at week thirty-seven was unaware of the plan. Furthermore, the relevant hospital Trust had not adopted national guidance issued in September 2018 for consideration of delivery by caesarean section between weeks thirty-six and thirty-seven in Chloe’s circumstances. Consequently, Chloe was booked for planned caesarean section at week thirty-eight as per Trust guidance. At inquest the Trust accepted these were missed opportunities to avoid Chloe’s death and had they not been missed it is likely that Chloe would not have died because delivery would have occurred well before 19 June, or, if antepartum haemorrhage had occurred during admission, it would have been successfully managed.

Although not clearly causal or contributory to Chloe’s death, I identified the following serious issues from the evidence: -

• The maternity unit did not have a system or proforma to note down and pass on to clinicians information provided by the ambulance service via the dedicated phone line to the unit.

• Blood for urgent use in maternity unit surgery was not kept on or near to the maternity unit.

• There was delay in calling for the on-call consultant anaesthetist to attend once the emergency caesarean section had been called.

• There was no robust system in place for a major obstetric haemorrhage to be called and acted upon with resulting delay in the provision and use of blood products.

• There was insufficient co-ordination and oversight of the emergency team and roles and tasks in the surgical theatre, in particular in oversight of obtaining and use of blood products.

• Certain key equipment was not available for the maternity unit theatre: -
- A blood storage fridge.
- Warming equipment for women during surgery.
- Point of care testing anticoagulation equipment.