Coroner says 'delay' in treatment of Havant teenager Teegan Barnard, 17, contributed to death after ‘catastrophic’ labour

Teegan Barnard suffered a cardiac arrest two hours after delivering her healthy baby boy, Parker, at St Richard’s Hospital in Chichester on September 9, 2019.

The ‘small’ 17-year-old from Havant suffered a ‘major’ bleed giving birth to Parker, who weighed 9lb 9oz, losing almost four litres of blood. As a result of the bleed, Teegan was starved of oxygen and suffered a severe brain injury. She later died at her home on October 7, 2019.

SEE ALSO: Family pay tribute to Strep A victim

At an inquest at West Sussex Coroner’s Court, Dr Karen Henderson, the coroner, said the ‘prolonged’ inquest process had been a ‘challenging’ situation that had taken a ‘significant impact’ on all involved, before adding: ‘We must remember Teegan as someone at the very beginning of her adult life. She was greatly beloved by her family and loved her family in equal return.’

Differences of opinion over what caused the cardiac arrest were heard during the inquest. Dr Philip McGlone, a consultant anaesthetist who treated Teegan, had said it happened as a result of bronchospasm, when airways in lungs tighten. Another doctor thought she could have suffered an adverse reaction to drug Carboprost, a medication given in childbirth emergencies to stop her Postpartum haemorrhaging. Another expert thought Teegan was suffering with bilateral tension pneumothoracies, a severe condition in which air is trapped in the chest and puts pressure on the heart.

Amid opposing views, the coroner had previously called for expert witnesses to help determine if medical intervention could have made a difference before adjourning the inquest, which started in January, until October and then again until Wednesday. But the expert witnesses had disagreed over whether a potentially life-saving measure should have been undertaken sooner.

However, Dr Henderson said a ‘catastrophic inability to ventilate’ was crucial, with her telling the hearing she ‘accepted the evidence’ of Mr Ehab Bishay, a consultant thoracic surgeon at University Hospitals Birmingham. He had said the teenager was not responding to ventilation and began to suffer air ‘ballooning’ across her body, leaving her arms so swollen her medical name band had to be cut from her wrist. Speaking Mr Bishay said: ‘If you haven’t seen surgical emphysema, you might think anaphylaxis.’

Teegan’s medical team undertook abdomen incisions to release trapped air, believing this was primarily located in the space between her lungs. These incisions were followed by two more between the teenager’s ribs in another attempt to relieve pressure on the lungs – a procedure that should have been undertaken sooner, according to Mr Bishay.

The consultant said: ‘In my opinion the bilateral thoracotomies should have been undertaken sooner. Every minute counts. Had they been done sooner then that hypoxic brain (injury) would have been less likely.

‘If you look at post-mortem, it’s clear the hypoxic brain injury was the real cause of death. It’s my opinion she wouldn’t have died had they been performed sooner.’

But another expert witness, obstetric anaesthetist Dr David Levy, had said this was ‘hindsight bias’ and was not ‘barn door obvious’ as to the most pressing treatment given the complexities of the emergency.

However, the coroner, despite admitting bilateral tension pneumothoracies was a ‘rare complication’ and acknowledging the benefit of hindsight, said it should have been ‘considered and excluded at an early stage’ especially with there no evidence of anaphylaxis bronchospasms.

Dr Henderson, giving her conclusion, said: ‘(Tigan) had sustained an irrecoverable hypoxic brain injury following a prolonged cardiac arrest on emergence from a general anaesthetic after an emergency at St Richards Hospital Chichester. The cause of the cardiac arrest was due to bilateral tension pneumothoracies the cause of which remains unclear but in circumstances whereby a delay in the recognition and treatment thereof made a material contribution to her death.’

The coroner confirmed she would be writing a report to prevent future deaths after stating she was ‘concerned and wished to be reassured (the death) was not a systemic issue’.

Teegan’s mother Abbie Hallawell said in a statement after the hearing: ‘It’s almost impossible to find the words to describe the hurt and pain our family feel following Teegan’s death. The last three years have been a living nightmare which no parent should have to go through.

‘Our lives are not the same without Teegan. She was such a loving and caring girl who enjoyed things people her age did such as meeting friends and horse riding. She had an infectious personality and a wonderful smile. It’s devastating to think she’ll never get to fulfil her potential in life.

‘We’d like to thank the coroner for carrying out such a thorough investigation and listening to our concerns. While the inquest and listening to the evidence as to why Teegan died has been incredibly traumatic it’s something we needed to do to honour her memory.

‘We know nothing can bring Teegan back or fill the void in our lives. All we can do now is ensure Parker grows up fully understanding what he meant to Teegan, how much she loved him and how proud she would have been of him. Teegan may not be with us but she will always be a part of our family. All we can hope for now is that her death wasn’t totally in vain and improvements are made to help other mums. We wouldn’t wish the hurt and pain we continue to live with on anyone else.’

Medical director and chief of service for Women and Children at University Hospitals Sussex, Dr Tim Taylor, said: ‘We wish to extend our sincere condolences to Teegan’s family for their terrible loss. Her death was an extremely rare tragedy that we know has deeply affected everyone involved. We are determined that all possible learning from the inquest will be acted upon as we continue do all we can to improve our services for women and children in our care.’