A coroner found a "number of failings" in the care of a woman who died at Gloucestershire Royal Hospital after giving birth to her second child.

Rana Abdelkari, 38, died in the hospital in March 2021 after suffering a severe bleed in which she lost over six litres of blood while giving birth.

A coroner discovered multiple failings in Rana's treatment during an inquest into her death at Gloucestershire Coroners Court on Tuesday (March 8).

This included not referring Rana's care to a specialist obstetric team despite the fact that there were risk factors to consider, including female genital mutilation.

Rana's husband, Modar Mohammednour, described his wife as a ‘really beautiful woman who made a good connection with everybody’ and was an ‘amazing person’. 

He said: “I have no life now. Just pain. I miss my wife so much and just feel pain in my life all the time. I tell my daughters she’s in paradise now.”

Stroud News and Journal:

The inquest heard how Rana was induced at 39 weeks pregnant during a routine checkup 'without proper consent' being given. 

While her husband, Modar, 44, stayed at home looking after their other child, completely unaware of the ordeal Rana was going through.

When Rana's bleeding became more severe, there was confusion about the emergency call procedure, and the emergency call bell was not used to get help. 

The coroner also called attention to the language barrier Rana and Modar, her husband, faced. Rana and Modar were from Sudan, and spoke limited English.

Solicitor Hannah Carr, who represented the family, said: “A catalogue of serious and unforgivable failings led to Rana’s tragic and avoidable death. 

“I would like to convey my sympathy to Modar who deeply mourns the loss of his wife and their two little girls who desperately miss their mum.

Stroud News and Journal: Modar and Rana who moved from Sudan to GloucestershireModar and Rana who moved from Sudan to Gloucestershire (Image: Novum Law)

"I cannot begin to imagine how terrified Rana would have felt, without access to interpretation services and without access to her husband by her side.

“Lessons need to be learned from what happened to Rana and it must never happen again.”

Gloucestershire Royal Hospitals NHS Foundation Trust has apologised and said changes had been made to prevent further tragedies.

Professor Mark Pietroni, medical director and deputy Chief Executive, said: 

“The death of Rana following the birth of her baby is devastating for her family and we would like to extend our heart-felt sympathies to her family members. 

“We want to take this opportunity to apologise once again for the immeasurable distress that this loss has caused.

“We will carefully review the findings of this inquest with a view to ensuring that all lessons identified have been learnt and embedded into our day-to-day practice.  

“The circumstances leading to Rana’s death were immediately and thoroughly investigated. An independent safety investigation was conducted by the Healthcare Safety Investigation Branch (HSIB). 

“Alongside this, the Trust undertook further investigation to ensure clarity for Rana’s family regarding the cause of her death. 

“The findings of these investigations have been shared with Rana’s family and HM Coroner and we have implemented all 10 recommendations made in the HSIB report.  

“We are absolutely committed to delivering the safest possible service. 

“To do this we will invite external reviews where appropriate, and build on our commitment to listen to women, their partners and staff to create a culture that enables excellent care.”