Coroner criticises 'repeated failures' at clinic following death of woman who travelled to UK from Ireland to have abortion
A coroner has criticised "repeated failures" at a high-profile abortion clinic following the death of a mother of one, hours after she had a termination.
Dr Sean Cummings said the case involving Aisha Chithira, 31, who travelled to England from Ireland to have a termination at a Marie Stopes clinic in Ealing, was "desperately sad".
West London Coroner's Court heard Ms Chithira died in January 2012 following a late-stage abortion after being discharged from the west London clinic despite vomiting and feeling dizzy, and displaying symptoms that "were not appreciated as potentially sinister".
Ms Chithira suffered a tear to her uterus during the "blind" procedure performed under anaesthetic, as a surgeon struggled to remove a 22-week-old foetus from a womb that had not fully dilated.
Afterwards she vomited and complained of feeling unwell to her husband, but was helped into a taxi to a cousin's home in Slough by staff who had told her she could not stay overnight.
Later that night the mother suffered catastrophic internal bleeding of around two litres and died.
Dr Adedayo Adedeji, who performed the procedure, and nurses Gemma Pullen and Margaret Miller were charged with manslaughter by gross negligence and a health and safety breach but the case was dropped in 2016.
Recording a narrative verdict, acting senior coroner for west London Dr Cummings said the case had been "catastrophic" for all those concerned.
After the procedure Ms Chithira had "light bleeding", complained of feeling hot, thirsty and dizzy and fell to the floor, staff at the clinic reported.
However, observations taken by a nurse showed her blood pressure and pulse were normal and doctors told the court her symptoms were "atypical" or "unlucky".
This meant her position was "difficult to diagnose and consequently the severity was missed", the coroner concluded.
He said: "Her death resulted from the manifestation of a recognised complication of the procedure resulting in sometimes subtle and atypical symptoms and signs which were not appreciated as potentially sinister at the time.
"There were repeated failures of recording of observations by different clinicians involved in her care."
Ms Chithira, who was from Malawi but settled in the Republic of Ireland, had a history of non-cancerous growths around the womb called fibroids which made the procedure more complex.
She had decided to have an abortion after miscarrying twins at 30 weeks and then having her baby girl delivered by C-section, making her worry that childbirth was too much of a risk.
She had to wait a month to obtain a visa to travel to the UK after it became clear the procedure could not take place in Ireland, and consequently due to the late stage of the pregnancy a number of clinics would not accept her.
Ms Chithira's husband Ryan said in a statement released after the verdict that his loss was "compounded by the torturous process that has seen my wife's case dragged through the courts over the past six years".
Dr Cummings identified an "element of complacency" within the west London clinic, but said he could not return a verdict of neglect as invited because he was not satisfied there had been a gross failure.
Last month Ealing Council became the first in the country to create a protest-free safe zone outside the Marie Stopes clinic after concerns for patients.
Emma Doughty, a specialist medical negligence lawyer from Slater and Gordon, which represents Ms Chithira's family, said: "It is crucial that lessons are learned to ensure a tragedy like this never happens again.
"I hope that today's verdict marks a turning point in Ms Chithira's family being able to rebuild their lives."