Source · Prevention of Future Deaths

Rachel Hollister

Ref: 2015-0288 Date: 21 Jul 2015 Coroner: Wendy James Area: Gwent Responses identified: 0 / 1 View PDF

The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.

Date 21 Jul 2015
56-day deadline 15 Sep 2015 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.
View full coroner's concerns
Medical staff and porters either did not follow or were unaware of the Health Board's Protocols

Report sections

Investigation and inquest
On 15.04.13 commenced an investigation into the death of Rachel Hollister (d.o.b. 17.08.81). The investigation concluded at the of the inquest on 26.06.15. The conclusion of the inquest was Rachel Hollister died from natural causes as a result of a known but rare complication of pregnancy childbirth. The medical cause of death being: Amniotic Fluid Embolism
Circumstances of the death
During the early hours of 13th April 2013 Mrs Hollister presented unannounced to the Maternity Unit at the Royal Gwent Hospital. Mrs_ Hollister gave birth to her daughter, 2.40a.m. She suffered a retained placenta and was transferred to theatre for manual removal where she suffered a cardiac arrest and was pronounced dead at 6.25
a.m
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.

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Report details

Reference
2015-0288
Date of report
21 July 2015
Coroner
Wendy James
Coroner area
Gwent

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Sep 2015 (estimated).

Sent to

Aneurin Bevan University Health Board

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