Hospital neglect contributed to ‘tragic, avoidable’ death of mum and baby, coroner says

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The death of a mum and her baby after being neglected by hospital staff was both “catastrophic” and “avoidable”, a coroner has surmised.

Phumeza Gogela, a Manchester carer who grew up in South Africa and moved to the UK in 2007, was just 35 when she died in cardiac arrest, an hour after giving birth.

Her daughter, also named Phumeza, or ‘Phumey’, was delivered via emergency caesarean section at North Manchester General Hospital with severe brain damage.

The baby died eight months later.

A joint inquest at Manchester Coroners’ Court heard there was a ‘gross failure to provide basic medical attention’ to Ms Gogela and that both she and her baby could have been saved.

Assistant coroner Fiona Borrill concluded that the failures amounted to neglect, which contributed to the ‘tragic, catastrophic and avoidable loss of a young mother and her baby’.

Phumeza Gogela died an hour after her baby was delivered by emergency caesarean section
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Family Handout via MEN)

Ms Gogela, who was 28 weeks pregnant, went to the maternity assessment unit at North Manchester General Hospital at 1.05am on Christmas Eve, 2016, complaining of chest pain. She had suffered from breathlessness and a cough for the last seven days, according to reports from Manchester Evening News.

In a “breach” of protocol and guidance, basic physiological assessments on Ms Gogela and her baby were not carried out by medics, though she was later transferred to A&E following a consultation between two midwives and a doctor.

Initially, medics gave her a ‘working diagnosis’ of a pulmonary embolism, a condition fairly common in pregnant women. But as her condition worsened, and she was becoming ‘increasingly short of breath’, A&E staff became ‘increasingly concerned’ about her.

She was given two electrocardiograms and was referred for a chest X-ray, which the radiologist questioned because Ms Gogela was pregnant.

By 4.30am, Ms Gogela’s condition was ‘deteriorating rapidly’ and she went into cardiac arrest shortly after 5am. An emergency caesarean section was performed and her daughter was born at 5.15am.

The new mum was declared dead an hour later.

Ms Gogela went to the maternity assessment unit at North Manchester General Hospital shortly after 1am on Christmas Eve in 2016
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STEVE ALLEN)

A post-mortem report found Ms Gogela died of lymphocytic mycorditis, an ‘extremely rare’ condition, in which the heart becomes inflamed due to an accumulation of white blood cells.

Pathologist Dr Emyr Benbow said he had only seen ‘five or six cases’ of the illness in his 40 year career. It was thought the condition was brought on by a viral infection, he said, but tests to establish exactly which virus were inconclusive.

An ‘incident investigation report’ compiled by Pennine Acute Hospitals NHS Trust – which managed the Crumpsall -based hospital at the time – detailed several ‘missed opportunities’.

It found medical staff in both A&E and the maternity unit failed to realise the ‘severity’ of Ms Gogela’s illness. Had they done so sooner and taken appropriate action, Ms Gogela’s life could ‘possibly’ have been saved, the report found.

Ms Gogela didn’t have a clinical review when she arrived at the maternity unit, and she wasn’t transferred to A&E ‘in line with policy’ with emergency department staff ‘unaware she was coming’.

Upon her arrival at A&E she wasn’t taken straight to a care team, and instead had to wait 19 minutes – four more than the required time frame – to be triaged.

Consultants and senior clinicians weren’t called for until Ms Gogela went into cardiac arrest – four hours after she had arrived at hospital – and no-one was ‘willing to take ownership’ of her care, the report found.

A ceasarean section could have been performed sooner, the report found, which could have increased the chances of survival for both mother and baby.

The coroner said there had been a ‘serious underestimation’ of Ms Gogela’s condition after she was first admitted to the hospital, with the “severity and deterioration of her condition” not being recognised.

Delivering her narrative conclusion that Ms Gogela and her baby died ‘as a result of natural causes contributed to by neglect’, she added: “There were a number of missed opportunities which, on the balance of probabilities, would have prevented her death when she died and allowed her baby to be delivered in a better condition.”

The coroner said she was satisfied that improvements had been made at the hospital following the incident.

Dr Sarah Vause, medical director at St Mary’s Hospital, told the inquest at the time of Ms Gogela’s death, maternity services at NMGH had been found to be ‘inadequate’ by healthcare watchdog the Care Quality Commission, following ‘several poor outcomes’.

A joint inquest at Manchester Coroners’ Court heard there was a ‘gross failure to provide basic medical attention’ to Ms Gogela
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Manchester Evening News)

As a result senior staff from St Mary’s were drafted in a bid to improve performance at NMGH.

Following the inquest, Ben Gent, a solicitor at Slater and Gordon who represented Ms Gogela’s family said: “This was a tragic event which took place at a time when the family were expecting the joy of a new arrival.

“Instead, they were faced with the horror of two avoidable deaths. While nothing will bring Phumeza and Phumey back, the family are grateful that the inquest has led to a better understanding of the cause of their deaths and should help to reduce the chances of anything like this happening to other families.”

Mr Gent said the family had been ‘incredibly brave’ – and that they welcomed the rewriting of policies and procedures at the hospital.

Dr Chris Brookes, deputy chief executive and executive medical director for Northern Care Alliance NHS Foundation Trust, which managed the hospital under the now dissolved Pennine Acute Hospitals NHS Trust at the time of the incident, offered the family the Trust’s “sincere condolences and deepest sympathies”.

“Whilst both died of natural causes, we accept that there were failings in their care and we would like to sincerely apologise to their family for this.

“As a trust, we are committed to learning and steps to improve were taken across the former Pennine Acute Hospitals trust at the time.”

Dr Brookes went on to say the improvements that had been delivered and maintained included “increased investment, improved staffing, focused training and the appointment of a new leadership team to drive up quality, patient safety and performance”.

A spokesperson for Manchester University NHS Foundation Trust (MFT), which now runs the hospital, added: “We wish to again offer our deepest sympathies and condolences to the family of Phumeza Gogela and Phumeza Esther Gogela-Sam”.

“We are considering the Coroner’s findings carefully and we wish to apologise unreservedly again to Phumeza’s family for their losses.

“MFT has managed North Manchester General Hospital since April 2020 and we note all the evidence given at the inquest, which demonstrated a number of comprehensive improvements over the last five years to strengthen the processes and ensure that lessons were learnt to improve patient safety and care.”

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George Holan

George Holan is chief editor at Plainsmen Post and has articles published in many notable publications in the last decade.

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