6 hours agoShareSaveLisa Summers,Scotland health correspondent and Andrew PickenShareSaveLori QuateJust a week before she was due to give birth, Jacqui Hunter was given the devastating news that her daughter had died in the womb.Less than 24 hours later, Jacqui was also dead.The 39-year-old had been told she would have to give birth to her stillborn daughter, who was called Olivia, and was given medication to bring on the labour.Within hours Jacqui was having intense contractions and at one point slumped into the arms of her husband, Lori Quate, who thought she had fainted.As staff at Ninewells Hospital rushed to help her, she suffered a cardiac arrest.Jacqui died two hours later from an amniotic fluid embolism – a rare and life-threatening emergency.It was not until the next day that Lori found out his wife had been given eight times the recommended dose of the drug to bring on labour – a mistake which some experts say may have contributed to her death.Lori is one of dozens of people – families, midwives and experts – who have told a BBC Disclosure investigation that urgent action is needed to improve maternity safety in Scotland.They shared details of many of examples of poor and sometimes deadly care, with NHS resources increasingly stretched.The Scottish government say “significant progress” has been made in the last 20 years in reducing infant mortality and neonatal deaths, while a new programme of maternity unit inspections is helping to raise standards.But there are calls for a national review similar to one being carried out in England, where a series of independent reviews have found that hundreds of mothers and babies could have survived with better care.Fern PhotographyThe devastation of losing his wife and baby in the space of 24 hours is still firmly etched on Lori’s face five years on from the tragic incident.He says his wife was let down “in the most horrific way”.Jacqui was not told she had been given an overdose of Misoprostol, the drug used to bring on labour, even though some staff were aware of the error before her contractions started. Lori says that in Jacqui’s medical notes there is no mention of the drug error until after she was declared dead.He says, “Not going to Jacqui, their patient, and saying we have messed up. Jacqui had a right to know about that, and they kept it from her.” Lori – Mark QuateAn investigation into Jacqui’s death in 2020 was carried out by an NHS Tayside review panel. It acknowledged that amniotic fluid embolism (AFE) “can occur in any labour and it is not possible to be certain that in this case an AFE would not have occurred with the correct dose of Misoprostol”.But the panel added that “as it is known that higher doses of Misoprostol increase the risk of AFE, the incorrect dose must be considered as a major contributing factor to AFE and subsequent death”.The panel also said Jacqui should have been informed of the medication error. A fatal accident inquiry was then carried out, which published its findings last year. It concluded that it was possible, but not probable, that Jacqui’s death could have been prevented if she had been given the correct dose.The inquiry also made no finding in respect of discussing the overdose with Jacqui. A spokeswoman for NHS Tayside said it was “deeply sorry” for Lori’s loss and had carried out a number of internal investigations, and taken part in external reviews, following the death.”All recommendations identified in the reviews were fully accepted and, as a result, our systems and processes have been strengthened where required and improvements have been made to how we provide care,” she added.Lori fears that failings in maternity care in Scotland are not being examined in the same way that services are reviewed in England.He wants a Scotland-wide review similar to the one which is examining 2,297 cases of harm to babies and women under the care of Nottingham University Hospitals NHS Trust.Baby and maternal deaths are rare in Scotland but while making this documentary, we heard time and again from families, experts and staff about the challenges being faced by maternity and newborn baby services.We spoke to families left angry because they had to fight for answers after going through devastating experiences.They also feel shut out by health boards who they believe are more concerned with reputational damage than honesty and transparency.Staff members tell us they are working in conditions that are often not as safe as they should be for women and babies – sometimes due to understaffing, sometimes because less experienced employees have had to take on additional duties.Like the rest of the UK, Scotland has seen an increase in Caesarean sections, inductions of labour, serious tears during childbirth and the proportion of babies born in poorer health. There have also been several spikes in neonatal deaths in recent years.These are clues that the system is not …
