On 14 May 2018, commenced an investigation into the death of Ifeoma Onwuka, 37years The investigation concluded at the end of the inquest on 20 December 2019. The conclusion of the inquest was a narrative, copy attached. including medical cause of death: CIRCUMSTANCES @F THE DEATH Mrs Onwuka was admitted to hospital for induction of labour: She was a high-risk labour due to induction, previous intra-uterine death of twins, age and ethnicity. Her labour progressed very quickly after 21.06 and she went from centimetres to fully dilated in a matter of minutes The was in distress, so an alarm was sent out and plans made to take her to theatre for a category 1 caesarean section However, the baby was delivered in the recovery room. Mrs Onwuka began to bleed s0 she was taken to theatre for examination under a general anaesthetic_ Just before induction of anaesthesia she had burning epigastric and before delivery had complained of difficulty in breathing: The anaesthetic care was excellent. The registrar could find no obvious source of the bleeding so called in the on-call consultant. He arrived and inserted a bakri balloon and conservative treatment was used until just after 01 OOhrs when she eventually had a hysterectomy which stopped the bleeding: She developed disseminated intravascular coagulopathy about 30 minutes after the anaesthetic: Blood and blood products were given as well as inotropes and vasopressors_ and baby pain

The consultant asked for a second consultant: He had not performed an emergency total abdominal hysterectomy before He had assisted at elective surgery_ He had three registrars present; one a general surgeon but did not choose to operate_ It appears that the first consultant who was called could not attend but that consultant then performed a ring around to find someone else to assist the original consultant: There did not appear to be a formal method of getting assistance_ Eventually, someone was found but he had to drive in from Norwich: At no time did I(on call Consultant) speak to the doctor who was coming in which could have been facilitated as he was not performing any surgery He said in evidence that it is not his normal practice to discuss cases with anaesthetists when he comes into theatre, he expects his registrar to give him information He does not; he says, ask for updates on the patient's condition, he relies upon the anaesthetist to inform him of any problem_ He was unaware or couldn't remember he said if he knew Mrs Onwuka was requiring adrenaline and vasopressors His evidence from the witness boX was that it was normal practice at the James Paget, Norfolk and Norwich and Addenbrookes hospitals to have 2 obstetric consultants to perform an emergency hysterectomy: Upon my checking this is not the practice at these hospitals and therefore have additional concerns that he gave this evidence on oathlaffirmation in a court of law: Of concern is that on the anaesthetist's evidence did not appear to know Mrs Onwuka had DIC, he made regular enquiries about her condition (contrary to his evidence) indicating a degree of worry or concern and that he did not agree with their repeated suggestions to proceed to an emergency hysterectomy much sooner_ It was clear from the evidence that there was no leadership in the care of Mrs Onwuka; the anaesthetists were supply organ support; but no-one took control of the overall situation. An expert instructed to assist the court has concluded that a delay in surgery to control the bleeding contributed to Mrs Onwuka's death. She was 37 years old and leaves 3 children.

In my opinion action should be taken to prevent future deaths believe you ANDIOR your organisation has the power to take such action: