Inquest: Young mum died after giving birth due to bad decisions by hospital staff

Jade Hart, originally from Pontefract in West Yorkshire, gave birth to Hugo in July 2018 at Bassetlaw Hospital in Worksop.

But she suffered a rare complication – a full uterine inversion, in which the placenta fails to detach from the uterine wall and pulls the uterus inside-out as it exits.

An inquest this month at Nottingham Coroner’s Court by Assistant Coroner Dr Elizabeth Didcock, came to the conclusion that Jade’s death was as a result of mistakes mainly by one of her doctors at the hospital.

The court heard the doctor pulled on Jade’s cord a further four times, conducting what is called Controlled Cord Traction (CCT) when the doctor shouldn’t have, an action determined as “a very serious omission of care” due to no signs of separation in relation to the placenta.

Jade suffered multiple cardiac arrests after the inversion but would not have died if it were not for the uterine inversion.

She suffered huge blood loss - 5.5 litres in total - had organ failure and brain damage, with neglect contributing to her death, the Coroner concluded.

Jade should have had an epidural (spinal nerve block), concluded Dr Didcock, but this was not given.

Thereafter, Jade relied on pain relief up to the point of birth.

Guidance in dealing with these problems were not followed.

After the inquest, Jade’s mother, Julie Hazelgrave, said that her daughter was “kind and caring with a great zest for life”.

When Hugo was born, Mrs Hazelgrave continued, “Jade was the happiest she had ever been”. But that happiness was short-lived as, within hours, her daughter collapsed and died.

Jade’s husband, Ric, said that the inquest was invaluable to the family’s understanding of what happened to her: “Ascertaining the facts is important, not least for our son, who now has to live his life without his mummy.”

Dr Didcock concluded that it was her hope that lessons were learned that will lead to improvements in care in the future.

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