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Nigerian mother dead after UK hospital "failure"


- Tracey Treanor

(Saturday, December 11, 2004)

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[ A scan revealed she had a massive bleed in her brain, and she died three days later on June 26. ]


A failure to promptly refer a mother-of-six to a community midwife was a factor in her death from pre-eclampsia nine days after giving birth, a Coroner said on Thursday last week. Chinyere Emerah, 34, underwent a normal delivery at Northwick Park Hospital and was discharged on 17 June 2003 when she should have been referred to a community midwife in her area and visited the following day. But St Pancras Coroner Dr Andrew Reid said: "I'm satisfied that when the deceased was discharged she was not referred to the appropriate community midwife, or at all." When Mrs Emerah, who was living in temporary accommodation at Britten Close, Golders Green, was eventually referred on June 22 to the nurses at the Royal Free Hospital this was only because she had called Northwick Park Hospital complaining of various symtons including generalised pain.

She was taken to the Royal Free in Hampstead later that day by ambulance along with her new born baby and small child- and after she was observed walking around, interacting with her children and the painkillers she was given had taken effect she was discharged home with instructions to return the following day for a scan. But Mrs Emerah had been suffering from the effects of pre- eclampsia and by the time she was admitted by ambulance the following day she was unconscious. A scan then revealed she had a massive bleed in her brain, and she died three days later on June 26.

Mrs Emerah, a mother of six married to Chief Michael Emerah, had travelled to the UK from Nigeria seeking a hearing test for one of her children. However after the medical consultant for her child, Nigerian airlines deemed her too heavily pregnant to fly and she had to wait until after the birth. Pre- eclampsia following pregnancy is very rare condition - so rare this was the only recorded case in the UK during the whole of 2003. However, Dr Reid pointed out that had Mrs Emerah been correctly referred she would have contacted her midwife as soon as she began having symptoms and a diagnosis could have been narrowed down.

At a previous hearing which had to be adjourned, the inquest heard from Donna Thornley from Northwick Park, who explained that she believed Mrs Emerah had been referred to the Barnet and Chase Fram Hospital. However today Barnet's head of midwifery Carol Littlehales said NW11 (Golders Green) was not their catchment area and if they had received referral in error they would have a record of it- and would have informed the referring hospital.

Dr Reid also noted that had Mrs Emerah been seen on the day after her discharge her blood pressure would have been recorded and could have been compared to a reading a few days later- high blood pressure being a symptom of pre- eclampsia. When Mrs Emerah presented to the hospital with "unusual symptoms" without having seen a midwide or having historical blood pressure readings, the "chance had been lost by the failure to refer", said Dr Reid. The coroner recorded a verdict of natural causes associated with adverse incidents.

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