Evening Telegraph (First Edition)

Widower scathing of medical staff ‘errors’

A WOMAN who died at Ninewells Hospital the day after her baby was “let down” by medical profession­als, according to her grieving husband.

Jacqui Hunter from Angus died in 2020 due to a rare obstetrics complicati­on, known as amniotic fluid embolism (AFE).

Tragically, her baby daughter Olivia died in utero on May 12, the day before she was admitted to hospital.

A fatal accident inquiry (FAI) into Ms Hunter’s death has concluded and a written determinat­ion from Sheriff Jillian Martin-brown will be published at a later date.

Dundee Sheriff Court heard Ms Hunter suffered a 700% overdose of the labour-inducing drug misoprosto­l.

It was previously revealed NHS Tayside has since increased protective measures relating to the drug.

The FAI is focused on the care and treatment provided by the medical staff at Lochee Medical Practice and Ninewells and establishe­s whether steps might have been taken to avoid death.

Unlike criminal proceeding­s, FAIS are inquisitor­ial in nature and used to establish facts rather than apportion blame. The court probe was fixed on a discretion­ary basis, with a procurator fiscal stating Ms Hunter’s death occurred in circumstan­ces “giving rise to significan­t public concern”.

Ms Hunter’s widower, Lorimark Quate, issued a scathing assessment of the actions taken.

He criticised midwife Sally Mcmartin for describing Ms Hunter as experienci­ng “mild to moderate” contractio­ns when she was “screaming in pain”.

Mr Quate said there were “discrepanc­ies” in Ms Mcmartin’s evidence and accused her of “under-reporting, understati­ng and unreliabil­ity” in her documentat­ion and note-taking.

She was also accused of not telling Ms Hunter about the drug error. “Jacqui was let down by those expected to look after her,” Mr Quate told the inquiry.

“The key to this case pivots upon whether hyperstimu­lation was present or not.

“The answer has come from myself, who was in the room the entire time.

“Hyperstimu­lation was occurring and the drug error must have been a causal factor.

“(Sally Mcmartin) had full awareness of the drug error. She did not read the drug protocols because ‘nobody reads them’.”

Ovarian hyperstimu­lation occurs when the ovaries become bigger and release chemicals into the bloodstrea­m.

Mr Quate claimed Ms Mcmartin said there had been 10 cases of hyperstimu­lation in the course of her 17 years as a midwife.

He said this was countered by another doctor who said that hyperstimu­lation was a “daily occurrence” on the ward.

Dr Philip Owen previously told the inquiry there was an opportunit­y to limit Ms Hunter’s overdose by trying to retrieve some of the tablets that had been administer­ed vaginally.

When offered the opportunit­y to share his thoughts on the inquiry by Sheriff Martin-brown, Ms Hunter’s father, John Hunter, said: “Unfortunat­ely, a lot of people are not doing the right thing and that bothered me.

“There appears to be an easygoing, laissez-faire attitude in the department where people cannot follow protocols without fear of consequenc­es.

“I am bitterly disappoint­ed in the actions of many of the people who have been involved in this.”

Helen Watts KC, representi­ng

NHS Tayside, expressed her sympathy for Mr Quate, highlighti­ng his detailed written submission­s, made without legal representa­tion.

“Sally Mcmartin’s evidence about what she noted has to be considered,” she said.

“It’s not the case that the only evidence is what she wrote down on that day.

“You have to consider the detailed evidence she gave about whether she saw any evidence of hyperstimu­lation. The very best clinicians don’t always make the best notes.

“It is not for Mr Quate – and I mean this with the greatest of respect – to decide what a midwife should or should not do.

“Mr Quate refers to an overarchin­g lack of compliance and refers to a deliberate and wilful neglect and that does not reflect the evidence the inquiry heard.”

Prior to closing the inquiry for her determinat­ion, Sheriff Martin-brown said: “It’s been a very detailed inquiry and quite upsetting for everyone involved.

“You (Mr Quate) have managed to conduct yourself with dignity throughout and you have done Ms Hunter and the rest of the family very proud.”