Friday, January 7, 2022

East Kent Hospitals Trust: Back in the news again: Inquest opens into the deaths of two mothers who tragically died of herpes shortly after giving birth. Question of the day: Why did it take a BBC investigation to figure out that both C-sections were performed by the same locum doctor, who could have infected the women with herpes?..."Kim Sampson, 29, from Whitstable, and Samantha Mulcahy, 32, from Hawkinge, died in 2018 after undergoing Caesarean sections at hospitals in east Kent. The coroner had originally decided not to hold inquests into their deaths - but an investigation later found both C-sections were performed by the same locum doctor, who could have infected the women with herpes. Neither woman had a history of the virus. Following the revelations, last week it was confirmed the coroner had performed a U-turn and an inquest was opened today at Archbishop’s Palace, Maidstone."


PASSAGE OF THE DAY: "More than a year after the women died, their families each received a letter from the coroner, Katrina Hepburn, saying there would be no inquests into their deaths. The letters acknowledged there had been a similar case but said there was "no connection" between the two deaths. They also set out the investigating pathologist's belief that the women had been infected with herpes "prior to hospital admission" But BBC journalists who have been investigating the East Kent Hospitals Trust's maternity services since 2019 turned their attention to the deaths of Kimberly and Samantha in the spring of this year. While reviewing documents sent to the families, they found Public Health England (PHE) had looked into how the women could have come into contact with the herpes viruses. Kimberly's family requested PHE gave them access to that investigation, and were sent redacted emails sent between staff at PHE, East Kent Hospitals Trust, other NHS bodies and a private laboratory called Micropathology. The emails showed PHE's investigation continued even after the coroner told the families no inquests would be taking place. The emails also revealed a significant link between the two deaths: that the same surgeon and midwife had taken part in both Kimberly's and Samantha's C-sections. Micropathology was asked to examine the two viruses the women had been infected with, to see if they were genetically identical and could have come from the same place. The emails show the parts of the virus that were tested were identical. In one email, someone working for Micropathology said both cases "look like surgical contamination". 

STORY: "Inquest opens into deaths of new mums Kim Sampson and Samantha Mulcahy who died after being infected with herpes,"  by Reporter Brad Harper, published by KentOnline on January 4, 2021.

GIST: "An inquest has been opened this morning into the deaths of two Kent mums who tragically died of herpes shortly after giving birth.


Kim Sampson, 29, from Whitstable, and Samantha Mulcahy, 32, from Hawkinge, died in 2018 after undergoing Caesarean sections at hospitals in east Kent.


The coroner had originally decided not to hold inquests into their deaths - but an investigation later found both C-sections were performed by the same locum doctor, who could have infected the women with herpes.


Neither woman had a history of the virus.


Following the revelations, last week it was confirmed the coroner had performed a U-turn and an inquest was opened today at Archbishop’s Palace, Maidstone.


The cause of death of both women was confirmed as multi-organ failure after contracting herpes.


Area coroner for central and south east Kent, Katrina Hepburn, told the inquest both families “had no objection the cases are linked”.


Speaking of Mrs Mulcahy, she said: “This case is similar in nature and was discontinued following an investigation in 2019.


“It has since came to light that the herpes infection was related to the Caesarean section.”

Both cases were adjourned to February 21 where a pre-inquest review will take place.


Neither family were in attendance this morning - but they have welcomed the news a full inquest will be held.


Last week Kim's mother Yvette Sampson told KentOnline: "We're very pleased that it's finally going to be happening.


"We've waited since 2018, so it's been a long while.


"We're just hopeful we will get from the inquest the answers that we need, for ourselves and obviously our grandchildren.”


Meanwhile, Ryan Mulcahy, Samantha's husband told the BBC that "not knowing what happened has worsened the pain and the suffering from losing Sam".


Samantha's mother Nicky said: "How did Sam and Kim get the virus, and from where? You feel like you are stuck and you can't move forward because you haven't got the answers you should have had."


The decision to open inquests more than three years after the women's deaths comes after a BBC investigation uncovered details of efforts made behind closed doors to establish any links between the two tragedies.


Tragic deaths after C-sections

Kim Sampson, a "bright and bubbly" barber and mum to a three-year-old daughter, lived at her mother's home in Newton Road, Whitstable.


After a smooth pregnancy, she went into labour at Margate's QEQM Hospital on May 3, 2018. 


She experienced complications, and it was eventually decided to perform a C-section.

Baby Albie was delivered healthy, but Kimberly required a blood transfusion following the operation.


She was discharged with Albie two days later, at her request, but was in a lot of pain and barely able to walk.


Her condition deteriorated over the following days and she was eventually taken back to hospital by ambulance, where she was treated on the maternity ward for bacterial sepsis - a potentially fatal condition - with antibiotics.


But her condition continued to worsen, so she underwent a series of operations to identify and treat the infection.'


Eight days after she was readmitted, a consultant microbiologist suggested trying the antiviral drug Aciclovir, which is used to treat herpes infections.


It was only after Kimberly was transferred to King's College Hospital in London that she was diagnosed with a catastrophic herpes infection.


She was given just "hours or days" to live and died on May 22.


Six weeks later, nursery nurse Samantha would die of the same virus at the William Harvey in Ashford, which is also run by East Kent Hospitals.


She had gone into labour four days before her due date, and after 17 hours of contractions and some concerning blood test results was taken for a C-section.


The operation was performed by the same doctor who had delivered Kimberly's baby.


Samantha's daughter was born healthy, but the new mum was kept in for observation because doctors were concerned about signs of the blood pressure condition pre-eclampsia.


These were no longer visible three days later, but Samantha continued to deteriorate, with her stomach swelling and her temperature and blood pressure rising.


Like Kimberly, doctors thought Samantha was suffering from bacterial sepsis so she too was given antibiotics, which did not work.


As her organs began to shut down, she was taken to intensive care, where she stayed for four days.


A doctor suggested she be treated with antiviral medication, but they were advised by the microbiology department to continue with antibiotics instead.


Doctors called for support from a hospital in London, and surgeons took her into the operating theatre to try to stabilise her, but she died on July 4.


"They told us that unfortunately they couldn't save her - that she'd gone, passed away," her mum, Nicola Foster, told the BBC.


The post-mortem investigation found Samantha had died from multiple-organ failure following a "disseminated herpes simplex type 1 infection".


Herpes is generally passed on by skin-to-skin contact, and almost 70% of adults have one of its two strains by the time they are 25.


Some people will develop cold sores or genital herpes, but about two-thirds will have no, or mild, symptoms.


Analysis of medical records revealed neither Kimberly or Samantha had previously had herpes, so would not have built up any natural protection against the virus.


Women in the late stages of pregnancy also have less protection from their immune system.


Investigation carried out behind closed doors

More than a year after the women died, their families each received a letter from the coroner, Katrina Hepburn, saying there would be no inquests into their deaths.


The letters acknowledged there had been a similar case but said there was "no connection" between the two deaths.


They also set out the investigating pathologist's belief that the women had been infected with herpes "prior to hospital admission".


But BBC journalists who have been investigating the East Kent Hospitals Trust's maternity services since 2019 turned their attention to the deaths of Kimberly and Samantha in the spring of this year.


While reviewing documents sent to the families, they found Public Health England (PHE) had looked into how the women could have come into contact with the herpes viruses.


Kimberly's family requested PHE gave them access to that investigation, and were sent redacted emails sent between staff at PHE, East Kent Hospitals Trust, other NHS bodies and a private laboratory called Micropathology.


The emails showed PHE's investigation continued even after the coroner told the families no inquests would be taking place.


The emails also revealed a significant link between the two deaths: that the same surgeon and midwife had taken part in both Kimberly's and Samantha's C-sections.


Micropathology was asked to examine the two viruses the women had been infected with, to see if they were genetically identical and could have come from the same place.


The emails show the parts of the virus that were tested were identical.


In one email, someone working for Micropathology said both cases "look like surgical contamination".


In another email, a Micropathology worker says "it seems the most likely explanation [is] that these strains are probably the same… which also adds weight to the idea that these two women were infected with the same virus."


The laboratory asked East Kent Hospitals Trust to provide a mouth or lesion swab from "the suspect surgeon in O&G (obstetrics and gynaecology)", but this was not provided.


In a statement, the Trust said the surgeon underwent a verbal occupational health check, where he said he had no history of herpes infection and had no hand lesions, although he was not tested for the virus at the time of the operations.


KentOnline understands the surgeon no longer works for the Trust.


Sexual health consultant Peter Greenhouse - who has 30 years experience in the field, and a particular interest in the herpes viruses - reviewed the cases and uncovered documents for the BBC.


Contrary to the pathologist's opinion, Mr Greenhouse believes the most likely scenario is that the infection was passed on accidentally by the surgeon carrying out the C-sections, through the women's abdomens."


The entire story can be read at:

https://www.kentonline.co.uk/whitstable/news/inquest-opens-into-deaths-of-mums-after-c-sections-260100/

PUBLISHER'S NOTE: I am monitoring this case/issue. Keep your eye on the Charles Smith Blog for reports on developments. The Toronto Star, my previous employer for more than twenty incredible years, has put considerable effort into exposing the harm caused by Dr. Charles Smith and his protectors - and into pushing for reform of Ontario's forensic pediatric pathology system. The Star has a "topic"  section which focuses on recent stories related to Dr. Charles Smith. It can be found at: http://www.thestar.com/topic/charlessmith. Information on "The Charles Smith Blog Award"- and its nomination process - can be found at: http://smithforensic.blogspot.com/2011/05/charles-smith-blog-award-nominations.html Please send any comments or information on other cases and issues of interest to the readers of this blog to: hlevy15@gmail.com.  Harold Levy: Publisher: The Charles Smith Blog;


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Executive Director: New England Innocence Project;
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