Content warning: the subject matter in this article may be upsetting to some readers.
One mum tragically passed away just seconds after seeing her newborn son for very first time.
The late Bernadette Horsey, from Nottingham, died in childbirth after suffering a 'profound, catastrophic collapse' mere moments after welcoming her baby, Tim, to the world.
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Horsey, who was just 31 years old at the time, suffered a cardiac arrest and died at the Royal Derby Hospital last year (19 January) and an inquest into the horrific situation has been launched.
The inquest commenced yesterday (4 October) when the Derby Coroner’s Court heard there was a 'clear and critical change' in Horsey’s health within the space of just 60 seconds.
Dr Martyn Traves, a consultant anaesthetist at the University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), has said he believes Horsey, who worked as a biomedical scientist who worked for the Nottingham University Hospitals NHS Trust, died from an amniotic fluid embolism.
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This effectively means that amniotic fluid, the liquid that surrounds the fetus during pregnancy, enters the bloodstream and causes a reaction which can stop the heart.
"All diseases have spectrums," he said. "Some people have different reactions to it and in this case, it was a profound, catastrophic collapse.
"There was no way of predicting that."
The consultant continued: "In about 60 seconds we went from relative normality to a catastrophic position. "I am certain that this was an amniotic fluid embolism."
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When asked by Louise Pinder, assistant coroner for Derby and Derbyshire, whether there were any missed opportunities to save Horsey, Traves replied: "Not as far as I’m aware of. We reacted quickly to what was happening in front of us.
"Sadly, I don’t think we could have done anything to change that."
The medical professional said there were no concerns over Horsey's health until seconds before she entered cardiac arrest.
He told the court that immediately following Tim’s delivery, he went to inject Horsey’s hand with oxytocin, a routine procedure, but he noticed her hand was in an unexpected position.
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While he noted this was not abnormal, Traves said he paused the injection when Horsey continued to move unexpectedly as he noticed her face became 'extremely pale and mottled'.
Her eyes subsequently rolled back representing a 'clear and critical change' in her condition.
He declared Horsey to be in a tonic state, meaning her body had entered a seizure, just seconds after he had congratulated her on the birth of her son.
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"It was extremely evident that she was in a critically unwell position at that time," Traves said. "It was not obvious what had occurred."
Tragically, despite the hospital staff's best efforts, Horsey was declared dead at 11.45 am.
Horsey's death was one of three maternal deaths and four maternal collapses at the Royal Derby in the space of 16 months.
In a report issued in February this year, the Health and Safety Investigation Branch said that while there were no common themes, incidents could have been prevented had previous advice been implemented.
Widower Aaron, opened up about his late wife ahead of the birth saying she was 'scared of what was about to happen' and was specifically concerned 'about having a blood clot and dying suddenly', but had no concerns about the care given at the time.
"The screen was lowered and he (Tim) was just there," Aaron recalled. "She (Horsey) said 'It’s a boy'.
"It could have been 100 years we were looking at Tim. Then the screen was put back up again."
He went on: "As I turned back from the screen to look at her, I let her head down on the pillow and as soon as I took my hand out she just slumped towards me.
"I could not even process what was happening. It was just like this image does not make sense."
The inquest is expected to conclude on Friday (6 October).
If you have experienced a bereavement and would like to speak with someone in confidence, contact Cruse Bereavement Care via their national helpline on 0808 808 1677
Rhiannon Ingle