A sheriff has said an expectant mother who died at Ninewells the day after her unborn daughter did not die in vain.
Jacqui Hunter died on May 13 in 2020 after being admitted to the hospital in Dundee to deliver her baby Olivia, tragically found to have died in utero the day before.
Mrs Hunter, from Fowlis in Angus, died as a result of an amniotic fluid embolism (AFE), a rare obstetrics complication.
Hers was labelled “a very complex syndrome” in which a woman gets amniotic fluid into their bloodstream just before, during or immediately after childbirth.
A fatal accident inquiry was held into the 39-year-old’s death and it was revealed NHS Tayside has ramped up protective measures relating to a drug Ms Hunter was given while in hospital.
In her ruling, Sheriff Jillian Martin-Brown wrote: “Ms Hunter’s death and that of her baby Olivia were utterly tragic.
“Though I have made no formal findings, Ms Hunter’s death has led to a change in prescription practice at Ninewells Hospital in order to prevent such an error happening in the future and the issue has been raised nationally.
“Her death has not been in vain.
“I hope that this inquiry has addressed the concerns that he and Ms Hunter’s family have had about what happened to Ms Hunter and why.”
Overdose
At Ninewells, a dose of misoprostol was prescribed and administered to Mrs Hunter shortly before her death.
It is medication used to prevent and treat stomach and duodenal ulcers, induce labour, cause abortions and treat postpartum bleeding.
The dissolving, fingernail-sized tablets were administered vaginally an hour or two before the procedure.
Ms Hunter’s dose was between eight and 10 times the NHS Tayside guidance.
Once the overdose was noticed, no attempts were made to retrieve any trace of the two unabsorbed tablets.
The inquiry heard it is something for which there was no protocol.
Expert witness consultant obstetrician Dr Philip Owen concluded it was possible but not probable had Ms Hunter been administered the correct dose, her death could have been prevented.
Dr Owen also indicated an appreciable body of competent, responsible obstetricians would not have attempted to remove the misoprostol.
The inquiry heard that since 2020, issues around prescribing misoprostol have been raised nationally.
Since Ms Hunter’s death, a new triple-checked procedure was introduced at Ninewells.
‘Utterly tragic’
The FAI heard from Ms Hunter’s widower, Lori-Mark Quate.
The sheriff’s report stated: “He described her as the love of his life, an absolute ray of sunshine with a cracking sense of humour.
“Mr Quate felt lucky to have been loved by Ms Hunter and she made him want to be a better person. They were soulmates.”
The sheriff has also determined failure by Lochee Medical Practice to refer Jacqui Hunter to Ninewells hospital days earlier did not materially contribute to the development of AFE.
The full judgement can be read here.
