Finding into death of Sommer Bethany Warren

18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hypertensive encephalopathy in labour

An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on 6 October, her blood pressure was recorded as 200/120 mmHg but was not treated with antihypertensive medication or magnesium sulphate. Instead, the treating anaesthetist administered additional epidural analgesia, expecting this to lower blood pressure. At 1810 hours she became drowsy with eyelid flickering. At 1817 hours she suffered a generalised seizure caused by hypertensive encephalopathy. She arrested at 1823 hours; resuscitation commenced at 1826 hours (3-minute delay). She died at 1901 hours despite resuscitation. The coroner found that treatment with intravenous labetalol and magnesium sulphate at 1755 hours would have prevented the seizure and death. The failure to provide this treatment fell below the accepted standard of care.