Mother died after 'bad clinical decision' (From Your Local Guardian)

Mother died after 'bad clinical decision' at St George's Hospital

11:48am Monday 26th October 2009 in Wandsworth By Eleanor Harding

A new mother died in St George’s Hospital after drugs were withheld in a “bad clinical decision”, an inquest heard.

Laila Chowdhury's uterus failed to reduce in size after an emergency caesarean section and she lost more than two litres of blood.

The 24-year-old from Mitcham was at particular risk of complications as her labour had spanned two days at the Tooting hospital.

Coroner Dr Shirley Radcliffe said: “It seems that everyone had done the right thing but there was a bad clinical decision.

She added: “It [is] probably a matter of educating doctors and doctors getting more experience.”

Westminster Coroner's Court heard that Dr Harichandana Panjugala was reminded by anaesthetist Stephen Lewis on two occasions to set up an infusion of the drug syntocinon.

But she refused, claiming the patient was “stable” and her uterus had already contracted back to its normal size.

Sales assistant Mrs Chowdhury was admitted to hospital on February 8 complaining of abdominal pain, the inquest heard.

The Bangladeshi woman had an emergency caesarean section the next day and her healthy baby was born.

But despite heavy bleeding, Dr Panjugala decided not to put her patient on a drip of drug syntocinon as recommended in hospital guidelines.

The patient was further put at risk when the hospital bank was unable to find the correct blood for a transfusion.

Mrs Chowdhury’s lungs failed and she died five weeks later.

Dr Radcliffe added: “Tragically she did not revive despite the best possible treatment she could have received and in the presence of a considerable number of trained doctors at St George's.”

Her death was caused by lung failure due to an internal haemorrhage as a complication of pregnancy.

The coroner recorded a narrative verdict.