'Neglect' issue in mother's death

Sue Gregory, Cardiff and Vale NHS Trust
Ms Hassell said Mrs Hureh died of a large intracranial haemorrhage, caused by pre-eclampsia and Syntometrine - which is used to stimulate the womb to contract and help the delivery of the placenta, but which should not be used on patients with high blood pressure.

She said: "All the opportunities that were not taken up to recognise her high blood pressure culminated in what has been described to me as a critical and unforgivable error of giving her Syntometrine.

"Those treating Ifrah know that Syntometrine should not be given to a woman suffering from pre-eclampsia.

"Nevertheless, they gave her Syntometrine because they didn't recognise the pre-eclampsia and didn't check again immediately before giving as to whether it was contra-indicated.

Ifrah Hureh already had nine older children

"The plan to give Syntometrine had been made some weeks earlier, but this had not be reviewed immediately before the drug was administered."

The coroner explained the legal definition of neglect was a gross failure to provide basic medical attention.