Source · Prevention of Future Deaths
Rachel Hollister
Ref: 2015-0288
Date: 21 Jul 2015
Coroner: Wendy James
Area: Gwent
Responses identified: 0 / 1
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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
Coroner's concerns
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
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