Gross failure' in mother's care

A mother-of-11 who died shortly after delivering twins suffered a "gross" failure in basic medical care, an inquest in Cardiff has been told.

Ifrah Hureh, 38, died of an intracranial haemorrhage after pre-eclampsia symptoms were not acted upon by University Hospital of Wales staff.

Mrs Hureh, who had moved from Somalia to Adamsdown in Cardiff, died hours after her twins' births in March 2008.

A senior midwife acknowledged there was "gross failure" in the mother's care.

Bernadette Moss was asked by city coroner Mary Hassell: "Was the care of Ifrah Hureh appropriate?" The midwife replied: "No."

The coroner asked: "Did she receive the basic medical attention you would expect?" Again the midwife replied: "No."

Pre-eclampsia

The coroner finished by asking: "In your view, do you think that the failure in basic medical attention Ifrah received was gross?"

Ms Moss replied: "Yes, I would."

The midwife earlier said it was the first maternal death she had experienced in her 30-year career and that procedures had since been tightened.

The pregnancy had been deemed to be a high risk one because Mrs Hureh had given birth nine times.

The inquest heard Mrs Hureh was found to have elevated blood pressure and high levels of protein in her urine - both symptoms of pre-eclampsia - while on the maternity ward.

Not concentrating

Had the high blood pressure been acknowledged appropriately, Mrs Hureh would also not have been administered Syntometrine in order to stimulate the womb to contract and help the delivery of the placenta.

This drug is not to be used when high blood pressure is detected.

Evidence was heard from midwife Sylvia Castello who failed to recognise Mrs Hureh's blood pressure was higher than it should have been.

Ms Castello said she had not been feeling too well during her shift and was not concentrating properly.

She apologised to the family of Mrs Hureh at the inquest, including her husband Ibrahim Yassin.

Urgent attention

Midwife Louise Protheroe Davies said she forgot to send Mrs Hureh's urine sample for tests and failed to take hourly blood pressure tests after she had given birth by 0430 BST on 28 March, 2008.

About three hours later Mrs Hureh deteriorated and urgent medical attention was called for, the inquest heard.

Audrey Long, a consultant obstetrician at the hospital at the time, admitted that Mrs Hureh did not receive "appropriate care."

She said she had been on duty until the evening of 27 March and was back in work the next day at 0830 BST when efforts were being made to resuscitate the mother.

She said she would have expected the high blood pressure readings to be brought to her attention on 27 March by the midwives monitoring Mrs Hureh, but it was not done.

Ms Hassell asked Ms Long: "Was it that you were so taken up with a woman who was high risk with her babies that you took your eye off the ball regarding her?"

The consultant, who now works in Stoke-on-Trent, replied: "I think so."

Midwife Ms Moss had been on duty overnight on 27 March and said she had not been told of Mrs Hureh's symptoms at any stage.

If she had been, she said, she would have acted immediately.

She said she could not find a reason why the high blood pressure readings were not passed on.

The inquest was adjourned until Thursday