16 Nov 2011

Queen’s Hospital neglect contributed to mother’s death

In a very rare ruling, a coroner has found that a serious failure by the Queen’s Hospital in Romford contributed to the death of Tebussam Ali, known as Serena.

Serena Ali who died at Queen's hospital Romford

Mr Chinyere Inyama found that the death of Mrs Ali was due to natural causes contributed to by neglect. First time mother Mrs Ali was admitted to Queen’s Hospital Romford on January 23 for a planned induction. The coroner found that: “there was a serious failure to monitor and observe her properly after the commencement of the induction process during which her uterus ruptured leading, ultimately, to cardiac arrest and her death five days later.”

Mrs Ali’s baby daughter Zainab was stillborn. In court on Wednesday the coroner said: “The absence of help amounted to a gross failure to take basic observations and examinations of an utterly dependent woman. It is more likely than not that if observations and monitoring had been carried out, there would have been a different outcome.”

When Mrs Ali collapsed on the antenatal ward and the call went out for a crash team, one midwife said she’d finished her shift and threatened to go home. When she stopped breathing, the oxygen mask was missing. The team performed an emergency caesarian on the bed but there was no resuscitation cot ready for baby Zainab. Instead a doctor had to run to the labour ward with her in his arms.

Very unusually, the coroner said that he would be writing to the Department of Health, the Nursing and Midwifery Council and the CQC [NHS watchdog], to recommend that the guidance on monitoring and observing women whose labour has been induced should be made more explicit.