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Hospital in ‘serious failings’ over mum who bled to death
9:03am Wednesday 11th December 2013 in News
A HOSPITAL was criticised for serious failings after a woman bled to death.
PC Diane Patt, 34, died hours after giving birth to her daughter at Colchester General Hospital.
The girl was safely delivered, but Mrs Patt suffered a massive haemorrhage and lost up to six litres of blood, which were not replaced.
Coroner Caroline Beasley-Murray said the hospital had failed in its care of Mrs Patt.
She said: “There were very serious failings in the care Mrs Patt received. With the appropriate and timely treatment, Mrs Patt might have survived. Her death was contributed to by neglect.”
Mrs Beasley-Murray said there was a failure of communication between the clinical teams, lack of leadership to deal with the developing situation and lack of clear, overall co-ordination and team work.
It emerged during the inquest surgical teams had not followedasurgical safety check list.
During the three-day hearing, the inquest was told doctors worked to stem Mrs Patt’s bleeding after the birth. Mrs Patt, of Nayland Road, Colchester, was admitted on September 18, 2011.
She asked for a natural birth, having had a Caesarean during the birth of her first child, a boy.
She gave birth to her daughter with the aid of a suction device called a ventouse, at 8.20pm, after a failed forceps delivery. Problems arose afterwards, when staff noted she was suffering “torrential bleeding”.
At the time they estimated she had lost about 2.4 litres of blood. In fact, she had lost more than twice that amount.
She was pronounced dead at 11.57pm. A post-mortem showed cause of death as cardiac arrest, caused by massive blood loss.
The coroner described the hours before Mrs Patt’s death as confused and “chaotic’’. She said: “The decision to attempt an instrumental delivery represents sub-optimum care and the decision to use forceps also represented sub-optimum care.”
Mrs Patt’s widower, Sgt Major Jason Patt, of the 7th Parachute Regiment, Royal Horse Artillery, attended the hearing with other members of the family, whom Mrs Beasley-Murray praised for the way they had handled Mrs Patt’s death.
Widower: Our devastation at care errors
A WIDOWER says his family have been left devastated by hospital errors that claimed his wife’s life.
Sgt Major Jason Patt said he hoped Colchester General Hospital had learnt from the mistakes that caused Diane’s death.
Mrs Patt, 34, a police officer based in Colchester, suffered a fatal heart attack after losing five litres of blood. Coroner Caroline Beasley-Murray found “very serious failings’’ in the case and said death was contributed to by neglect.
In a statement after the verdict, Sgt Major Patt, of Colchester’s 7th Parachute Regiment, Royal Horse Artillery, said: “My family has been devastated by the errors made by the hospital.
“It has taken a wonderful mother and wife away from us.
“I had many unanswered questions before the inquest and I am pleased the coroner has carried out such a thorough review.
“She identified a succession of very serious failings in Diane’s care, but my familywill nowhave to deal with the consequences.
“I can only hope the hospital learns from its mistakes, so the same does not happen to someone else.”
Mr and Mrs Patt’s daughter is now two. The couple’s son is aged four.
Paul Sankey, a clinical negligence lawyer with London-based Slater and Gordon, said: “A thorough investigation by the coroner has revealed devastating criticisms of Mrs Patt’s management.
“It is difficult to understand why anaesthetists failed to respond to Mrs Patt’s extensive blood loss and to give her adequate replacement fluids.
“It seems clear with adequate management she would not have died and proper care would have avoided such a catastrophic loss to her family.
"The clinicians need to learn from their avoidable errors and the hospital management must ensure all concerned learn from this tragedy.”
After PC Patt’s death, Lee Davies, her chief inspector at Colchester police station, said: “She was a fantastic officer, a credit to the force and her family.”
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