St George’s Healthcare response to BBC Panorama
This is an extremely sad case and our deepest sympathies go to the Ballantyne family.
At the public inquest, the coroner recorded that Suzanne’s death was unavoidable and recognised that medical staff did the best they could, correctly following protocols in use at the time.
Regarding the dose of Misoprostol administered
“At the inquest, the coroner recorded that Suzanne’s death was unavoidable and recognised that medical staff did the best they could, correctly following protocols in use at the time.
“The Misoprostol doses in the trust’s local protocol were based on a 2003 study published by the World Health Organization. The existing protocol was updated following the publication of NICE guidance in 2008; however, this new guidance did not make recommendations for specific dosages on the administration of Misoprostol. The 2008 guidance advised that the choice of drug and dose should take into account the clinical circumstances, availability of preparations and local protocol and experience.
“The maternity unit at St George’s Hospital had been using this dosage regime of Misoprostol since October 2003 without any serious complications, so it was still considered a safe and effective intervention.”
Regarding the implementation of guidance received in November 2010
“In line with other NHS trusts, our protocols for the administration of medications and treatments are developed using NICE guidance, published studies, Cochrane Collaboration reviews, royal college reviews, peer consultation and committee reviews. Whenever new guidance is published, the guidance is carefully reviewed by the maternity unit’s guideline development group before being implemented.
“New guidance for the administration of Misoprostol, published by the Royal College of Obstetricians and Gynaecologists in November 2010, was implemented by the trust in February 2011, following a thorough review by the trust’s guideline development group.”
Regarding the consultant attending
“At the time of Suzanne’s arrest the medical team was fully focused on performing cardio-pulmonary resuscitation (CPR) and managing her blood loss, so did not inform the consultant straightaway. When Suzanne’s condition deteriorated, despite every effort at resuscitation, the consultant on-call for obstetrics was alerted and attended immediately. An additional senior obstetric consultant also attended.
“The coroner made it clear at the inquest that had a consultant attended at an earlier stage this would not have saved Suzanne’s life. The trust has learned lessons however and has enhanced its training programmes and reviewed protocols to ensure that staff seek a higher level of clinical leadership at the correct time.”
Notes to editors
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