Experts criticise care of tragic mum-to-be, 45
INDEPENDENT doctors today criticised how medics handled the care of a pregnant woman who died after being starved of oxygen.
The medics told an inquest that Joanne Lockham’s baby was not delivered quickly enough and a decision to proceed with a general anaesthetic was a “disaster”.
Mrs Lockham, 45, died two days after giving birth by caesarean section at Stoke Mandeville Hospital, Aylesbury.
Mrs Lockham, a nurse at The Chiltern Hospital, Great Missenden, had conceived with IVF treatment.
The Wendover resident suffered cardiac arrest as the child, who survived, was delivered – but life-saving tubes were not put in place correctly to give her oxygen.
Dr Richard Pyper, an independent consultant obstetrician, said the baby should have been delivered when tests were made at 4.30pm on October 9 2007.
He said: “The vast majority of clinicians would have recommended urgent delivery at this stage.”
The decision was taken to perform a caesarean section at 6.05pm and performed at 7pm.
Yet this time gap was “unacceptably long” and the operation should have been carried out within 30 minutes, he said.
There was “plenty of time” to top up the pain-relieving epidural, he said, meaning there would have been no need for the more risky general anaesthetic.
If this had been done “the baby would have been delivered at 6.37pm and all the subsequent events would have been avoided” he said.
Dr Pyper said: “If there was concern about the condition of the foetus as there had been in this case for at least four hours you would want the baby to be delivered within half an hour.”
The inquest has already heard that anaesthetics trainee Dr C. Nagendra Prasad twice incorrectly inserted the tubes, a procedure known as intubation.
He was joined by fellow anaesthetist Dr Frederick Smith who re-aligned the tubes, but again this was incorrect.
It was only when senior consultant Dr Alex Bogdanov arrived about half an hour later that the oxygen supply was correctly put in place.
This crucial window of time was analysed today by Dr Felicity Plaat, consultant anaethetist, who commented on how Mrs Lockham was positioned.
Dr Plaat said: “It is possible that this extreme tilt, by tilting her further may have made the management of the airway more difficult”.
She said the mask appeared to have “slipped out of place so the airway was lost”.
The monitors did not show carbon dioxide leaving her body the hearing was told, meaning Mrs Lockham was not receiving oxygen.
Yet this was not picked up by Dr Prasad and Dr Smith.
Dr Plaat said: “It should have been clear that maternal oxygenation could not be easily maintained at all.
“She should have been allowed to wake up and alternative strategies considered once senior help arrived.”
She said it was “disastrous” that Mrs Lockham was re-anesthetised instead of being allowed to wake up and breathe unaided.
Dr Plaat said there was a “failure to follow the failed intubation drill” drawn up by hospital managers to deal with such emergencies.
She pointed to a statement yesterday from Dr Bogdanov who said he had “never seen an obstetrics patient with oxygen levels so low”.
Dr Plaat said: “Every opportunity to rectify the situation was missed.”
Mrs Lockham, who was pregnant with her first child, died two days later from a brain injury caused by a lack of oxygen.
Dr Bogdanov was called back to the stand by a juror who asked what training was in place to deal with similar events.
The medic said: “Failed intubation is something that will happen again. That is the nature of the situation we are in.”
Such situations “are extremely rare” he added and said “we keep retraining this part of training again and again and again”.
Buckinghamshire coroner Richard Hulett will sum up the case on Tuesday and jurors will then be asked to retire to return a verdict.