Source · Prevention of Future Deaths

Rachel Hollister

Ref: 2015-0288 Date: 21 Jul 2015 Coroner: Wendy James Area: Gwent 0 responses identified · 1 indexed addressee View PDF

AI-generated concerns summaryMedical staff and porters were unaware of or did not follow Health Board protocols, and the major obstetric haemorrhage protocol did not align with Royal College guidelines.

Date 21 Jul 2015

56-day deadline 15 Sep 2015 est. estimated from the report date

Responses identified 0 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Medical staff and porters were unaware of or did not follow Health Board protocols, and the major obstetric haemorrhage protocol did not align with Royal College guidelines.

View full coroner's concerns

Medical staff and porters either did not follow or were unaware of the Health Board's Protocols The major obstetric haemorrhage protocol does not meet the guidelines published by the Royal College of Obstetricians and Gynecologists and and end and

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.

Similar PFD reports

Shared signals

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 from the report date).

Sent to

Aneurin Bevan University Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.