A doctor who refused to give crucial clotting drugs as a mother lay dying in an operating theatre followed the wrong set of guidelines, an inquest heard today.
Gabriela Pintilie gave birth to her healthy baby girl, Stefania, in February last year following a C-section at Basildon Hospital in Essex.
But tragically the 36-year-old suffered a massive postpartum haemorrhage and died from a cardiac arrest hours later after a series of complications at Basildon Hospital in Essex.
The Romanian-born mother lost a total of six litres of blood after delivering her baby girl, but was not given clotting drugs which could have saved her.
A three-day inquest at Essex Coroner’s Court has been told how the on-call haematologist – who was at home – was called but refused to give permission for vital blood-clotting drugs to be issued until further tests were run.
Gabriela Pintilie, 36, (pictured with husband Ionel) lost a total of six litres of blood after giving birth to her daughter Stefania (right) via C-section last February
But today, an expert witness said she believed the use of clotting drugs in the ‘extreme situation’ would have ‘significantly increased’ the chances of a different outcome for Mrs Pintilie
On-called locum haematologist Dr Asad Omran did not initially issue blood-clotting drugs because the expert witness said, he was following the wrong protocol.
He was said to have been following protocol for a normal adult, instead of a woman in labour, which was ‘completely at odds with clinical guidelines’.
Dr Omran was at home when he received a call asking for permission to release clotting drugs but did not give the go-ahead.
The inquest heard how the consultant haematologist – an agency worker who had been at Basildon for four months – was blamed for contributing to Gabriella’s death.
Another doctor told investigators he believed the actions had ‘played a part in Gabriela’s death’.
The Romanian-born mother bled to death over several hours after a breakdown in communication between hospital staff at the controversial maternity unit
The inquest heard how Dr Omran spoke of his regret for events last February.
‘I regret my part in any miscommunication or misunderstanding that night’, the inquest heard, he was to later tell investigators.
He said he’d made the ‘assumption’ clotting drugs had been administered.
‘On reflection I could have taken care to check that this was the case,’ he said.
He told the inquest that when he’d been called at home he had NOT asked about Gabriela’s blood loss and he did not ask if she had been given blood clotting drugs.
Dr Omran did not have any access to Gabriela’s medical notes whilst he was at home.
Despite the tragic death, he only wrote a half page of handwritten notes two months after Gabriela died.
‘I never experienced this situation before’, he said.
The inquest heard how clotting products requested to the theatre were left outside the room whilst Gabriela was suffering massive blood loss which then triggered a cardiac arrest.
Essex Coroner Caroline Beasley-Murray said from her reading of reports: ‘It would appear that not everyone in the theatre knew that this blood had come’.
The hospital’s maternity unit has been linked to a series of tragedies in recent months. Pictured: Basildon University Hospital
Mrs Pintilie’s husband, Ionel, talked today of the chaotic scenes at the hospital as he was asked if he agreed to his wife undergoing a hysterectomy to save her life.
Speaking through a translator he said: ‘There was no time to think but I immediately agreed to this.
‘This would then save my wife. I could not process what was happening. It all happened so quickly.
‘I went into the room to see what was happening… the doctor said the situation was critical, that she had lost four litres of blood. I realised how bad things were, how critical it was.’
The widower today thanked medical professionals for trying to save Gabriela.
‘I would like to thanks the doctors and nurses who took part in this operation, but would also like to say from their point of view, they did everything they could, but I lost my wife.
Robert, Gabriela and Lonel Pintilie. Gabriela gave birth to her daughter in February last year, but died the following day at Basildon University Hospital
‘The children are fine but imagine that she does not have a mother’, he concluded.
More than a dozen people were in the busy theatre as Mrs Pintilie started to haemorrhage blood.
Even when her heart stopped, some of the medics were still unaware that the fresh frozen plasma, to aid clotting, was in a fridge in an adjacent ‘satellite’ room next to the operating theatre.
Honeymol John, a nurse who was in the theatre, told investigators in a statement: ‘After the patient’s death I spoke with Dr Tom Hall [the anaesthetist] and Dr Olubukunola Ojo, [consultant] and both said they were unaware that the FFP (fresh frozen plasma) had been in a satellite fridge.
Dr Hall, in charge of monitoring Gabriela’s blood loss in the surgery, described yesterday how Dr Omran refused to issue blood-clotting products, such as frozen fresh plasma, to the theatre.
Hall said Dr Ojo called Dr Omran at about 12.15am to request clotting products but was told they would not be released until the latest blood test results had been returned.
Expert witness Dr Felicity Plaat , said she was shocked by the failure to use clotting drugs which would have ‘significantly increased’ the chances of a different outcome.
‘It’s obvious that this was a catastrophic haemorrhage… what strikes me is the lack of blood products,’ she said.
She later added: ‘My gut feeling is that the outcome would have been different.’
Dr Plaat said she was also ‘profoundly shocked’ that Dr Omran was not aware of the two different procedures.
‘It’s my person belief there was a delay in definitive surgical management as well,’ she concluded, suggesting Mrs Pintilie should have undergone her hysterectomy at an earlier stage.
The inquest continues.