A pregnant woman and her baby died after paramedics took her to a hospital 10 miles away rather than the nearest A&E.
Estherline Caulker, 39, was stuck in rush-hour traffic for 84 minutes after the London Ambulance crew failed to realise she was suffering from internal bleeding after being taken ill at a train station.
It was the first in a series of failings that saw her go into cardiac arrest and die in hospital from an internal haemorrhage early the following morning. Her premature daughter was delivered by emergency caesarean but died two months later.
Ms Caulker’s death was the fifth maternal death in 18 months involving the Homerton hospital. It has led to whole-scale changes in procedure at the hospital, in Hackney, and across the London Ambulance Service.
Coroner Mary Hassell said Ms Caulker “would probably have survived” had she been taken on sirens and blue lights to a closer emergency unit and received better care.
Her father, Starlingford Caulker, 66, told of a “loving” daughter who had suffered four miscarriages and desperately longed for a child.
He told the Standard: “She always wanted to have a child. That was her greatest dream. And she would have made the best mother in the world.
“We are all absolutely devastated. She was a wonderful daughter. I can’t even bear to look at pictures of her. If I do, it’s like my heart is breaking.
“We will have a meeting as a family and consider taking legal action. But justice can never be done because nothing can bring her back.”
Poplar coroner’s court was told that fast-response paramedic Alex Boda correctly suspected “significant bleeding” when he arrived at Kensal Rise station at 5.41pm on January 16. He called for an ambulance to take Ms Caulker, who was 26 weeks’ pregnant, to hospital, believing her condition was potentially life-threatening.
But rather than rushing her to St Mary’s in Paddington or the Royal Free in Hampstead – 10-minute emergency journeys – the crew took her as a non-urgent case to the Homerton, where she was receiving antenatal care. They did this “in line with her wishes” and after believing she had stabilised. She arrived at 8.07pm and was not seen by a doctor for two hours after a breakdown in communication between midwives.
Paramedic Paul Quarterton said: “General practice is to take ladies to their booked maternity unit. At the time, I believed we were making the best decision for the patient.”
Asked by the coroner if he had failed to appreciate it was a medical emergency, Mr Quarterton replied: “Yes.” He added: “I didn’t appreciate at the time the nature of the urgency. If I had, I would have been more forceful with the patient about where we were going to go.”
Yashwant Koak, a consultant general surgeon who tried to save her life, said she would have had a 75 per cent chance of survival if she had been taken to A&E as scans would probably have picked up the bleeding from her splenetic artery. “If it’s recognised within the ‘golden hour’, the outcome is a lot different,” he said.
“By the time the patient came to Homerton, it was likely to have dropped down to 50 per cent. At the time of the crash call [when she went into cardiac arrest], it would have been less than five per cent.”
Ms Caulker, from Hackney, a sales manager at Ladbrokes, weighed almost 20st and was classed as morbidly obese. Pathologist Ula Mahadeva said obesity was a “recognised risk factor” for maternal death and “have made the diagnosis and resuscitation more difficult”.
Ms Hassell praised the “bravery” of junior doctor Harry Gibson, who led the initial attempt to save Ms Caulker’s life while also performing an emergency caesarean on a mother in the next room when her child’s heartbeat plummeted.
She said: “Everybody who looked after Ms Caulker had to go to work the following day. Some had to go from her devastating situation literally moments later to another devastating situation of potentially life-threatening circumstances.
“That must have been a very difficult thing to do, particularly when one recognises that one has not dealt with the situation in the way that one would like, it does take quite a degree of bravery to go into that situation and do one’s best.”
Dr Gibson, an obstetric registrar, apologised to Ms Caulker’s family, some of whom were in tears as they heard evidence. “I look back on it and I wish I had done hundreds of things,” he said. “I would like to say how sincerely sorry I am for everything that has happened.”
Ms Hassell said: “What I have heard, and wholeheartedly accept, is at the very outset there was an opportunity to treat Ms Caulker. That probably would have been effective. As time went on, that opportunity got smaller and smaller. By the time she was given CPR, it was next to nothing.
“Undoubtedly Miss Caulker died from natural causes but there were opportunities in her care to recognise how ill she was. These opportunities were not seized.”
The inquest heard that triage midwife Natalie Allen put a post-it note on Ms Caulker’s file marked “urgent”. But obstetric assessment unit midwife Tayo Olofowobi admitted she had failed to treat it as a priority and gave up trying to find a doctor because the department was “busy”.
Hospital staff ignored the reports from paramedics detailing her low blood pressure and it took two hours before Ms Caulker was seen by a doctor.
In a narrative verdict, the coroner said the ambulance crew had been “falsely reassured” about her condition.
Ms Hassell said: “This was a life-threatening medical emergency and should have prompted an immediate blue-light transfer to the nearest appropriate emergency unit, regardless of any later improvement.
“There was a failure of fully effective communication between health professionals at every stage in Ms Caulker’s care on the evening of the 16th and the early morning of January 17, between solo paramedic and ambulance paramedics; ambulance paramedics and triage midwife; triage midwife and midwife with care; midwife with care and obstetric registrar.
“If blue light transfer to an emergency unit with maternity support had been effected from the railway station where she was taken ill, then, following diagnosis of a collection of blood via a FAST scan and immediate surgery, she would probably have survived. By the time she reached the Homerton Hospital Maternity Unit, treatment was unlikely to change the outcome.”