Case example 6. Clinical example of missed opportunities for intervention30
| A woman with risk factors for pre-eclampsia presented at term with an abnormal fetal heart rate trace. She had an emergency caesarean birth. Postnatally she had significantly abnormal renal, liver and clotting function but there was no direct consultant obstetric involvement and the severity of her illness was not recognised until very late. There were differing opinions about transfer to intensive care and despite multiorgan problems she remained in the obstetric high dependency unit. She continued to deteriorate with markedly abnormal liver function, but at no point was a gastroenterology or hepatology opinion sought. She eventually died from her liver failure several days after giving birth. There was no post-mortem or serious incident review carried out. At all stages the severity of her underlying pathology was underestimated and opportunities to escalate her care were missed. |