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Royal Free Hospital issued with warning following mother's death

View profile for Guy Pomphrey
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The Care Quality Commission (“CQC”) has issued a ‘warning notice’ the Royal Free Hospital in London because their inspectors identified serious safety failings with the NHS Trust’s maternity unit.

An unannounced CQC inspection of the Hospital’s maternity service took place in October 2020 following the death of a 34 year old woman, Ms Karama, earlier in February 2020.

Ms Karama died whilst giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol (medication used to induce labour).  In a report following an inquest into Ms Karama’s death, the Coroner said:

“Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids.  The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.”

The Royal Free Hospital have reported that changes have been made to their systems since Ms Karama’s death; specifically, that it is now mandatory for a medical review before misoprostol is given to a multi gravida mother (a woman who is pregnant for at least a second time).

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