A woman who died at Ninewells Hospital the day after her baby was “let down” by medical professionals, according to her grieving husband.
Jacqui Hunter from Angus died in 2020 due to a rare obstetrics complication, known as amniotic fluid embolism (AFE).
Tragically, her baby daughter Olivia died in utero on May 12, the day before she was admitted to hospital.
A fatal accident inquiry (FAI) into Ms Hunter’s death has concluded and a written determination from Sheriff Jillian Martin-Brown will be published at a later date.
Dundee Sheriff Court heard Ms Hunter suffered a 700% overdose of the labour-inducing drug misoprostol.
It was previously revealed NHS Tayside has since increased protective measures relating to the drug.
Husband’s summation
The FAI is focused on the care and treatment provided by the medical staff at Lochee Medical Practice and Ninewells and establish whether steps might have been taken to avoid death.
Unlike criminal proceedings, FAIs are inquisitorial in nature and used to establish facts rather than apportion blame.
The court probe was fixed on a discretionary basis, with a procurator fiscal stating Ms Hunter’s death occurred in circumstances “giving rise to significant public concern.”
Ms Hunter’s widower, Lori-Mark Quate, issued a scathing assessment of the actions taken.
He criticised midwife Sally McMartin for describing Ms Hunter as experiencing “mild to moderate” contractions when she was “screaming in pain”.
Mr Quate said there were “discrepancies” in Ms McMartin’s evidence and accused her of “under-reporting, understating and unreliability” in her documentation and note-taking.
She was also accused of not telling Ms Hunter about the drug error.
“Jacqui was let down by those expected to look after her,” Mr Quate told the inquiry.
“The key to this case pivots upon whether hyperstimulation was present or not.
“The answer has come from myself, who was in the room the entire time.
“Hyperstimulation was occurring and the drug error must have been a causal factor.
“(Sally McMartin) had full awareness of the drug error.
“She did not read the drug protocols because ‘nobody reads them’.”
Dispute over hyperstimulation
Ovarian hyperstimulation occurs when the ovaries become bigger and release chemicals into the bloodstream.
Mr Quate claimed Ms McMartin said that in the course of her 17 years as a midwife, there had been 10 cases of hyperstimulation.
He said this was countered by another doctor who said that hyperstimulation was a “daily occurrence” on the ward.
Dr Philip Owen previously told the inquiry there was an opportunity to limit Ms Hunter’s overdose by trying to retrieve some of the tablets that had been administered vaginally.
When offered the opportunity to share his thoughts on the inquiry by Sheriff Martin-Brown, Ms Hunter’s father, John Hunter, said: “Unfortunately, a lot of people are not doing the right thing and that bothered me.
“There appears to be an easy-going, laissez-faire attitude in the department where people can not follow protocols without fear of consequences.
“I am bitterly disappointed in the actions of many of the people who have been involved in this.”
‘Not for husband to decide midwife actions’
Helen Watts KC, representing NHS Tayside, expressed her sympathy for Mr Quate, highlighting his detailed written submissions, made without legal representation.
“Sally McMartin’s evidence about what she noted has to be considered,” she said.
“It’s not the case that the only evidence is what she wrote down on that day.
“You have to consider the detailed evidence she gave about whether she saw any evidence of hyperstimulation.
“The very best clinicians don’t always make the best notes.
“It is not for Mr Quate – and I mean this with the greatest of respect – to decide what a midwife should or should not do.
“Mr Quate refers to an overarching lack of compliance and refers to a deliberate and wilful neglect and that does not reflect the evidence the inquiry heard.”
Prior to closing the inquiry for her determination, Sheriff Martin-Brown said: “It’s been a very detailed inquiry and quite upsetting for everyone involved.
“You (Mr Quate) have managed to conduct yourself with dignity throughout and you have done Ms Hunter and the rest of the family very proud.”
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