Scotland's Maternity Crisis: Questions remain over drug overdose

Lori-Mark Quate’s request for the Nursing and Midwifery Council (NMC) to review its decisions relating to the midwives involved in his late wife’s care represents the latest step in his quest for answers and, above all, accountability.

Read more here: Exclusive: Scotland's Maternity Crisis: Husband condemns regulator inaction after death of wife following overdose

An NHS Tayside review panel noted that although an amniotic fluid embolism (AFE) can occur in any labour,” it was known that higher doses of Misoprostol increases the risk of the rare, life-threatening emergency. As such, it said the incorrect dose administered to Jacqui Hunter “must be considered as a major contributing factor to AFE and subsequent death.”

Lori-Mark Quate believes the issue of hyperstimulation in his wife’s death was too readily dismissed. Picture: Lisa Ferguson | Lisa Ferguson/The Scotsman

A fatal accident inquiry (FAI) into Ms Hunter’s death heard that in hindsight, the midwife who administered the Misoprostol regretted not challenging the variation in prescribing Misoprostol doses when more often than not it was different to the protocol. However, it was also told she would never have administered a dose which was unusual or caused her concern.

Read more: Scotland's Maternity Crisis - A week-long series exposing nationwide problems and giving voice to families

The FAI also heard the midwife regretted not making more detailed notes about aspects of Ms Hunter’s care, in particular her observations on her contractions. The inquiry’s report described her recordkeeping as “inadequate” and not in accordance with NHS Tayside’s recordkeeping policy.

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But in her determination for the FAI, Sheriff Jillian Martin-Brown concluded that Ms Hunter was not hyperstimulated - a recognised side effect of Misoprostol. That is an issue that Mr Quate believes was too readily dismissed.

A spokesperson for NHS Tayside said: “The deaths of Ms Hunter and her baby daughter, Olivia, were a deeply tragic loss, and we continue to extend our condolences to Mr Quate and his family.

“NHS Tayside undertook a number of internal investigations and engaged in external reviews following the deaths to ensure all learning opportunities were taken by the organisation to deliver improvements. 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.

“NHS Tayside is committed to providing safe, compassionate, and high-quality services to women and families in our care. We also remain committed to continuously learning and improving so that we can offer the best possible support to every family we serve.”