Expert Lawyers Call For End To ‘Never Events’ After Mother Bled To Death

NHS Trust Admits Catalogue Of Errors That Caused Death Of Mum-Of-Five Following Caesarean


The husband of a mum-of-five who bled to death following a caesarean in what the NHS describes as a ‘never event’ has spoken of his ongoing anger and sadness that their children have been ‘robbed’ of a mother.

Rosida Etwaree lost over half her blood after undergoing an elective caesarean to deliver twins at the Mayday Hospital (now known as Croydon University Hospital) in South London on 23 June 2010, which caused a fatal cardiac arrest just hours later. She was just 45 years old.

Medical law experts at Irwin Mitchell instructed by Rosida’s husband Ahamud found a catalogue of ‘atrocious’ failings by Croydon Health Services NHS Trust which contributed to her death. In fact, Rosida was one of three women who died over a two-month period while in the care of maternity services at the same hospital.

An inquest into Rosida’s death remains unscheduled after the Coroner was so concerned at events surrounding her death he referred the case to the Crown Prosecution Service which is still investigating the possibility of a criminal prosecution.

Irwin Mitchell has now secured an undisclosed settlement from the Trust agreed at the High Court in London today (25 February) for the family’s loss, but Ahamud, who lives in Croydon, says nothing can make up for his children, now aged between 18 and three, growing up without their mother.

Ahamud has suffered flashbacks, nightmares and psychiatric injuries after witnessing his wife’s deterioration and as well as providing for the children, the funds will be used to treat his post-traumatic stress disorder and depression.

The settlement follows an admission of liability from the Trust in December 2012 and an official apology from the Trust’s Interim Chief Chairman a month later which confirmed Rosida died as a result of a ‘never event’ - problems which the NHS says are simply “unacceptable and eminently preventable”.

The eight-point list of core never events includes: In-hospital maternal death from post-partum haemorrhage after elective caesarean section

Expert medical evidence commissioned by Irwin Mitchell found that staff within the Trust failed to:

  • Provide appropriate supervision and guidance to junior staff during and after the caesarean section
  • Accurately record the extent of Rosida’s blood loss in theatre
  • Declare a major obstetric haemorrhage (in contravention of their own internal policy) which would have led to a better management of care
  • Adequately monitor Rosida following the surgery
  • Provide regular blood transfusions
  • Provide adequate record keeping and sufficient handovers between teams on shift changes
  • Identify the severity of Rosida’s condition and her need to return to theatre for further investigations

Louise Forsyth, a medical law expert at Irwin Mitchell is representing the family.

Expert Opinion
This is one of the most horrific cases I have come across and the failings of the Trust were nothing short of atrocious.

“To have a healthy woman die following childbirth in this way in the 21st century is almost incomprehensible, but to know that two other women died in the same time period suggests systematic failings throughout the maternity unit.

“Whilst we welcome the admission of liability and settlement for the family, Rosida’s death was entirely avoidable and nothing can make up for the family’s loss.

“Never events should be just that, events that simply do not happen and whilst we appreciate the Trust taking action and confirming lessons have been learnt, we expect these lessons to have been shared transparently throughout the NHS. This open approach is the only way to protect the safety of patients and prevent the same tragedy from happening again.”
Louise Forsyth, Associate

Rosida had been warned that one of the twins would not survive long due to a heart defect (Nabilah sadly died aged just two-years-old after spending most of her short life in hospital) so she was looking forward to spending what little time she could cradling the girls. However, she was so weak following the surgery she never got to hold either of them.

As the day progressed, Rosida’s condition continued to deteriorate but Ahamud said he felt helpless as he had to trust that the doctors and nurses knew what they were doing.

Ahamud, 42, who worked as a forklift truck driver before caring for the children full time, said: "I will never forget witnessing my wife suffer in such a horrendous way.

"I begged the doctors and nurses to help her, but they made me feel that I was panicking over nothing and that they had everything under control with the blood transfusions they had given her.

"Shortly after 7pm, a crash call was made as my wife’s heart began failing. I watched as the doctors and nurses rushed in and tried to resuscitate her and I could see her slipping away. Three hours later, the doctor came to me and told me Rosida had died. I hugged her helplessly not wanting to believe it could be true.

"No one could tell me how or why this had happened and as I struggled to come to terms with it, I couldn’t help but feel bitter anger towards the staff that were meant to have cared for Rosida."

He added: "I took legal action because I desperately needed answers about why our children had been robbed of their mum so I could begin to get my head round what had happened. I still don’t understand how my wife died from what the NHS calls a 'never event' - as it simply shouldn’t happen.

"As I hear of other cases where new mums or babies have died because of care failings by hospital staff, I can’t help but wonder how many more lives will be needlessly lost.

"More action needs to be taken throughout the NHS to improve resource and training for maternity staff to make improvements to services. Apologies for mistakes being made are welcome, but they mean nothing without everything possible being done to prevent the same errors happening time and time again."

Read more about Irwin Mitchell's expertise relating to birth injury claims.