Coroner’s health call after Rogerstone mum’s death

The move follows an inquest into the death of 27-year-old mother of two Yvonne Nyakuhwa, from Rogerstone, Newport, who died of septicaemia, or blood poisoning – after picking up a Group A streptococcal infection – four days after giving birth at the city’s Royal Gwent Hospital in April 2010.

Miss James recorded a narrative verdict of natural causes, namely a recognised complication following childbirth.

But she shared the concerns of Andrew Dawson, a now retired consultant obstetrician who investigated the circumstances of Mrs Nyakuhwa’s death. He concluded that a community midwife who visited Mrs Nyakuhwa after her discharge from hospital followed Aneurin Bevan Health Board guidelines in not taking general observations including measurements of temperature, blood pressure and pulse rate because Mrs Nyakuhwa had appeared well and said she felt well.

But he said those guidelines, while consistent with NICE (National Institute for Clinical Excellence) advice, were confusing and ambiguous, and not as clear-cut as those recommended by CEMACH (Confidential Enquiry into Maternal and Child Health).

These recommend that observations are carried out for several days after discharge, to be alert to insidious infection.

Gwent’s community midwives now routinely take observations from discharged mums on a first visit. But Miss James will ask health board chief executive Dr Andrew Goodall to consider revising guidelines so observations are taken for several days.

She also wants training for all hospitaland community-based staff in recognising early symptoms of sepsis (blood poisoning).

A health board spokesman said procedures on observation and monitoring of women following birth had been reviewed after Mrs Nyakuhwa’s death.

“Where this review has resulted in change being made, this has been communicated to allour maternity staff.”