AN investigation into the death of a woman after giving birth failed to identify several problems that led to her death, a report has said.

Laura-Jane Seaman had been admitted to Broomfield Hospital on December 21 2022 to give birth to her latest child, with a known history of haemorrhages which the hospital trust was aware of. While her birth itself was uneventful, she subsequently suffered a haemorrhage which was not noticed by staff for hours.

This was despite her pleas to them "not to let me die" and her losing consciousness in the hospital bed.

The 36-year-old from Witham died on December 23, and a coroner concluded in August there were multiple "basic failures" in her care and she had been neglected.

Laura-Jane attended Broomfield Hospital after experiencing contractions at home. She was nine months pregnant. Laura-Jane's labour progressed well and was relatively short.

After her birth she recovered well and was able to breastfeed her baby, was sat up in bed, and planned to go home following discharge of her baby. However, just under two hours later, Laura-Jane started to feel unwell and deteriorate.

An earlier inquest heard that Laura-Jane's deterioration in the hours after delivery was not recognised and was not escalated for more senior review. During her deterioration she asked clinicians "am I bleeding", said "I feel like I am gushing" and begged "please don't let me die". However, despite being at high risk of post-partum haemorrhage, her concerns were not escalated. Medical staff caring for her put her symptoms down to dehydration and when she lost consciousness, she was simply given a biscuit.

The clinical team labelled this loss of consciousness as a faint, however, expert evidence has confirmed that Laura-Jane had experienced a maternal collapse which warranted obstetric review.

A prevention of future deaths report from coroner Sonia Hayes has now set out matters giving rise to concern

This highlighted Laura-Jane was not escalated for hours as a deteriorating patient and was believed to suffering dehydration.

Her report said: "The maternal collapse was categorised as a "faint" by trust staff and Laura-Jane was treated for potential dehydration – with no apparent risk factors – and administered medication that had only a transient effect".

It added "The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs."

Laura-Jane's observations were recorded onto a cardiotocograph (CTG) print out rather than a Modified Early Obstetric Warning Score (MEOWS) chart, which meant that prompts for escalation on the MEOWS chart were not followed.

The prevention of future deaths report added: "Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team.

"The Trust Executive Review Group ("ERG") Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that "The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).

"The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration."

At around 6.30am on December 21 2022, Laura-Jane went into cardiac arrest as a result of major internal bleeding, finally identified following a bedside scan, resulting in her undergoing four surgeries, requiring multiple blood transfusions. There was a delay in the recognition and treatment of Laura-Jane's internal bleeding (haemorrhage) and the massive haemorrhage protocol was not triggered.

She added: "Quality of communication and handovers between Trust staff key information was omitted in handovers between staff at all levels including when Laura-Jane was taken to theatre as a medical emergency.

"Therapeutic anticoagulation was administered without consultant obstetric input, further medical review or imaging where there had been hours of deranged vital signs that were inconsistent potential complications for pulmonary embolism.

"No accounts were taken from Haematology, or the blood lab team involved with this massive haemorrhage by the Trust or the HSIB (who investigated this case) where massive amounts of blood products were prepared, dispensed and then administered where the timings and sharing of information were important to understand."

Diane Sarkar, Chief Nursing and Quality Officer for Mid and South Essex NHS Foundation Trust, said: "We extend our sincerest sympathies and condolences to the family of Laura-Jane.

"Her tragic death has affected us all at the trust greatly.

"Following investigations into the circumstances that led to her death, our focus has been on improving training in recognising the early signs of deterioration and escalation routes in our maternity services to prevent this from happening again."