Mother and baby died after neglect at hospital, coroner rules

Ma, 35, died from cardiac arrest and her baby from brain damage eight months later after they were neglected by hospital staff, coroner rules

  • Phumeza Gogela, 35, van Moston, died at North Manchester General Hospital
  • Haar dogter, also Phumeza, died eight months later with severe brain damage
  • She was born via emergency caesarean section an hour before her mother’s died
  • CoronersCourt told there was ‘gross failure to provide basic medical attention
  • Assistant coroner Fiona Borrill found that the failures had amounted to neglect
  • A mother and her baby daughter died after she was neglected by hospital staff, a coroner has found.

    Phumeza Gogela, 35, van Moston, died at North Manchester General Hospital after suffering a cardiac arrest.

    Haar dogter, also Phumeza, died eight months later with severe brain damage after she was delivered via emergency caesarean section an hour before her mother’s death.

    A joint inquest at Manchester CoronersCourt heard there was a ‘gross failure to provide basic medical attentionto Ms Gogela and both she and her baby could have been saved.

    Assistant coroner Fiona Borrill found the failures amounted to neglect, which contributed to the ‘tragic, catastrophic and avoidable loss of a young mother and her baby’.

    Phumeza Gogela (op die foto), 35, van Moston, died at North Manchester General Hospital after suffering a cardiac arrest

    Phumeza Gogela (op die foto), 35, van Moston, died at North Manchester General Hospital after suffering a cardiac arrest

    Ms Gogela, wie was 28 weeks pregnant, went to the maternity assessment unit at North Manchester General Hospital at 1.05am on Christmas Eve, 2016, complaining of chest pain, saying she had suffered from breathlessness and a cough for the last seven days.

    Basic physiological assessments on Ms Gogela and her baby were not carried out by medics ‘in breach of protocol and guidance’.

    Following a consultation between two midwives and a doctor, she was transferred to A&E.

    Aanvanklik, medics gave her a ‘working diagnosisof a pulmonary embolism, a condition fairly common in pregnant women.

    But as her condition worsened, and she was becoming ‘increasingly short of breath’, A&E staff became ‘increasingly concerned’ aangaande haar.

    A joint inquest at Manchester Coroners' Court heard there was a 'gross failure to provide basic medical attention' to Ms Gogela (op die foto) and both she and her baby could have been saved

    A joint inquest at Manchester CoronersCourt heard there was a ‘gross failure to provide basic medical attentionto Ms Gogela (op die foto) and both she and her baby could have been saved

    She was given two electrocardiograms and was referred for a chest X-ray, which the radiologist questioned because Ms Gogela was pregnant.

    By 4.30am, Ms Gogela’s condition was ‘deteriorating rapidlyand she went into cardiac arrest shortly after 5am.

    An emergency caesarean section was performed and her daughter was born at 5.15am. Ms Gogela was declared dead an hour later.

    A post-mortem report found Ms Gogela, a carer who grew up in South Africa and moved to the UK in 2007, died of lymphocytic mycorditis, an ‘extremely rare’ toestand, in which the heart become inflamed due to an accumulation of white blood cells.

    Pathologist Dr Emyr Benbow said he had only seen ‘five or six casesof the illness in his 40 year career.

    Dr Benbow said it is thought the condition was brought on by a viral infection, but tests to establish exactly which virus were inconclusive.

    An ‘incident investigation reportcomplied by Pennine Acute Hospitals NHS Trustwhich managed the Crumpsall -based hospital at the timedetailed several ‘missed opportunities’.

    It found medical staff in both A&E and the maternity unit failed to realise the ‘severityof Ms Gogela’s illness.

    Had they done so sooner and taken appropriate action, Ms Gogela’s life could ‘possiblyhave been saved, the report found.

    Ms Gogela did not have a clinical review when she arrived on the maternity unit, and she wasn’t transferred to A&E ‘in ‘line with policywith emergency department staff ‘unaware she was coming’.

    When she arrived at A&E she wasn’t taken straight to a care team, and instead had to wait 19 minute – four more than the required time frameto be triaged.

    Consultants and senior clinicians weren’t called for until Ms Gogela went into cardiac arrestfour hours after she had arrived at hospitaland no-one was ‘willing to take ownershipof her care, the report found.

    A ceasarean section could have been performed sooner, the report found, which could have increased the chances of survival for both mother and baby.

    The coroner said there had been a ‘serious underestimationof Ms Gogela’s condition after she was first admitted to the hospital.

    ‘Tragically for Phumeza, the severity and deterioration of her condition was not recognised,’ said Ms Borrill.

    Delivering her narrative conclusion Ms Gogela and her baby died ‘as a result of natural causes contributed to by neglect’, het sy bygevoeg: ‘There were a number of missed opportunities which, on the balance of probabilities, would have prevented her death when she died and allowed her baby to be delivered in a better condition.

    The coroner said she was satisfied that improvements had been made at the hospital following the incident.

    Dr Sarah Vause, medical director at St Mary’s Hospital, told the inquest at the time of Ms Gogela’s death, maternity services at NMGH had been found to be ‘inadequateby healthcare watchdog the Care Quality Commission, following ‘several poor outcomes’.

    As a result senior staff from St Mary’s were drafted in a bid to improve performance at NMGH.

    Following the inquest, Ben Gent, a solicitor at Slater and Gordon who represented Ms Gogela’s family said: ‘This was a tragic event which took place at a time when the family were expecting the joy of a new arrival.

    ‘In plaas daarvan, they were faced with the horror of two avoidable deaths. While nothing will bring Phumeza and Phumey back, the family are grateful that the inquest has led to a better understanding of the cause of their deaths and should help to reduce the chances of anything like this happening to other families.

    Mr Gent said the family had been ‘incredibly brave’ – and that they welcomed the rewriting of policies and procedures at the hospital.

    Dr Chris Brookes, deputy chief executive and executive medical director for Northern Care Alliance NHS Foundation Trust, which managed the hospital under the now dissolved Pennine Acute Hospitals NHS Trust at the time of the incident, gesê: ‘We would like to offer our sincere condolences and deepest sympathies to the Gogela family for their tragic losses following the very sad deaths of Phumeza Gogela and Phumeza Esther Gogela-Sam in 2016 en 2017 onderskeidelik.

    ‘Whilst both died of natural causes, we accept that there were failings in their care and we would like to sincerely apologise to their family for this.

    ‘As a trust, we are committed to learning and steps to improve were taken across the former Pennine Acute Hospitals trust at the time.

    ‘These improvements have since been delivered and maintained, reducing the risk of similar failings in future.

    ‘These steps included an Improvement Plan which addressed the required increased investment, improved staffing, focused training and the appointment of a new leadership team to drive up quality, patient safety and performance.

    A spokesman for Manchester University NHS Foundation Trust (MFT), which now runs the hospital, bygevoeg: ‘We wish to again offer our deepest sympathies and condolences to the family of Phumeza Gogela and Phumeza Esther Gogela-Sam, following their very sad deaths in 2016 en 2017 onderskeidelik.

    ‘We are considering the Coroner’s findings carefully and we wish to apologise unreservedly again to Phumeza’s family for their losses.

    ‘MFT has managed North Manchester General Hospital since April 2020 and we note all the evidence given at the inquest, which demonstrated a number of comprehensive improvements over the last five years to strengthen the processes and ensure that lessons were learnt to improve patient safety and care.

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