FAI DETERMINATION SUMMARIES

 

Fatal Accident Inquiries (FAIs) are held following a death in the workplace or in cases which give rise to reasonable suspicion. They are usually held in the sheriff court, but may be held in other premises when appropriate. Summaries provide the main findings in order to assist understanding and may be published in cases where there is wider public interest. They do not form part of the reasons for the findings.

The full Determination published on the Scottish Courts and Tribunals website is the only authoritative document.

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Once a Determination is delivered, it is not the role of the sheriff to enforce recommendations made, or to ensure compliance by any person who has provided a response to recommendations.

Jacqui Hunter

 

Oct 15, 2024

Sheriff Jillian Martin-Brown made no recommendations following a Fatal Accident Inquiry in to the tragic death of Jacqui Hunter but noted her death had led to a change in prescription practice at Ninewells Hospital in Dundee in order to prevent such an error occurring in the future. The Sheriff has also determined that the failure by Lochee Medical Practice to refer Jacqui Hunter to Ninewells hospital on Monday 11 May 2020, did not materially contribute to the development of AFE (amniotic fluid embolism) and Ms Hunter’s death.

 


Background

Jacqui Hunter was admitted to Ninewells Hospital in Dundee on 13 May 2020, to deliver a baby which was confirmed to have died, following an ultra sound scan the day before. Ms Hunter suffered a cardiac arrest due to contracting AFE (amniotic fluid embolism) during labour and subsequently died.

Findings

The scope of the Fatal Accident Inquiry was restricted to three issues:

  1. Did Ms Hunter report reduced fetal movements to Midwife Calder on Monday 11 May 2020 and might further investigations thereon have avoided her death?

     
    Ms Hunter attended Lochee Medical Practice in Dundee on 11 May for a pre-arranged midwife appointment at 39 weeks gestation with Midwife Abbie Carter.

    During the FAI there was a dispute between the parties as to whether Ms Hunter reported to the midwife that her fetal movements appeared to be reduced. If Ms Hunter had reported reduced fetal movements she ought to have been referred to Ninewells Hospital for further assessment.

     The Sheriff found the midwife and Mr Quate (the husband of Ms Hunter) credible and reliable witnesses. The midwife was certain that she had a conversation about fetal movements and that Ms Hunter reported no concerns, which was consistent with contemporaneous notes that she made in Ms Hunter’s records. Sheriff Martin-Brown attached more weight to the midwife’s evidence about what she remembered than to Mr Quate’s evidence which was based on what his wife had told him.

    Sheriff Martin-Brown accepted Mr Quate’s evidence that Ms Hunter had mentioned on both 10 May and following the consultation on 11 May, that the baby was being quiet and not kicking as hard.

    The Sheriff therefore determined that Ms Hunter experienced reduced fetal movements from Sunday 10 May onwards but on balance she did not accept that Ms Hunter had reported that reduction in movements to the midwife at the Lochee Medical Practice. Accordingly the Sheriff determined that it would not have been a reasonable precaution for the midwife to have referred Ms Hunter to Ninewells Hospital for further investigation.

    The Sheriff further determined that even if Ms Hunter ought to have been referred to Ninewells hospital, the failure to do so did not materially contribute to the development of AFE and Ms Hunter’s death. 

  2. Was Ms Hunter hyperstimulated as a result of the incorrect dose of misoprostol on Wednesday 13 May 2020 and might the correct dose have avoided her death?

     
    Mr McQuate was clearly of the view his wife was hyperstimulated following the overdose of misoprostol. Midwife McMartin regretted not making more detailed notes but she did document her last examination prior to Ms Hunter’s collapse  that she was satisfied there was no evidence of hyperstimulation. Expert evidence in the inquiry was supportive of the midwife’s position. The Sheriff therefore determined that Ms Huter was not hyperstimulated on Wednesday 13 May.

     The expert evidence from Dr Owen was that the rarity of AFE and the relative infrequency of the use of misoprostol 400 mcg after prior administration of mifepristone meant that a definitive expert opinion regarding the dose and subsequent death from AFE could not be reached. Dr Owen thought it was possible not probable that the overdose was a contributory factor in Ms Hunter’s death. Therefore it was possible not probable that if she had been administered the correct dose that her death could have been prevented. The Sheriff made no formal findings in respect of the overdose of misoprostol.

     

  3. Should Dr Northridge have discussed the overdose of misoprostol with Ms Hunter on Wednesday 13 May 2020 and might her death have been avoided had she tried to remove it?

    Sheriff Martin-Brown found Dr Northridge to be a credible and reliable witness. Expert evidence from Dr Owen indicated that an appreciable body of competent responsible obstetricians would not have attempted to remove the misoprostol. In light of that evidence Sheriff Martin-Brown did not find that Dr Northridge should have attempted to remove the misoprostol. Dr Owen also said the anticipated timeframe for sharing information in relation to the overdose fell within the range of practice adopted by other consultants.


Conclusion

The expert evidence meant that the Sheriff could not uphold submissions made by Mr Quate.  Mr Quate conducted himself with great dignity throughout all the preliminary hearings and the inquiry itself, despite having to listen to extremely distressing evidence. Sheriff Martin-Brown hopes the inquiry has addressed the concerns that he and Ms Hunter’s family have had about what happened to Ms Hunter and why.

 The full determination can be found on the Scottish Courts and Tribunals Service website