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The agonising wait for answers continues for the families of two mums who died following childbirth, after the inquest into their deaths was halted by last-minute legal challenges by a hospital trust.
Kent's senior coroner has demanded an explanation after the joint inquiry into the deaths of Kim Sampson, from Whitstable, and Samantha Mulcahy, from Hawkinge, had to be pushed back by almost two months today.
The mums died just six weeks apart in 2018 at two hospitals run by the East Kent Hospitals Trust, after they contracted infections caused by the herpes virus.
The county's coroner's service had originally decided not to hold inquests, but U-turned after it was suspected both C-sections may have been performed by the same surgeon, who could potentially have infected the women with herpes.
The full inquest was due to start on Monday and last for at least five days, but the trust submitted a last-minute request to restrict reporting of the names of certain members of its staff.
Despite there being at least three preliminary hearings – known as Pre-Inquest Reviews – where such a challenge could have been made, it was submitted just before 4pm on Sunday.
The application was opposed by lawyers representing the family, while submissions were also made by members of the press, including KentOnline, the Press Association and the BBC.
Following three days of legal arguments, the decision over restrictions is now set to be made on Tuesday – with timing issues forcing the inquest to be delayed until mid-April.
Assistant Coroner Catherine Wood, presiding, said the county's Chief Coroner Patricia Harding had requested the trust provide an explanation for the late timing of the submission, which she said had "clearly had an impact on all here."
Speaking to the family, she added: "I am terribly, terribly sorry that we are in the position we are in today, and not halfway through hearing the evidence as I had planned.
"I fully understand this has been a difficult week to prepare for, but at least you know the court and the service will do everything we can to make sure this runs as smoothly as possible in April."
Ms Sampson's mum, Yvette, said the actions of the trust "have just added to the pain and grief we feel".
"For years it’s felt a fight just to get to the stage of at least having an inquest into Kim’s death," she explained.
"While the feeling of hurt and loss at Kim’s death has never gone away, those feelings have really come to the fore again over the last few weeks as we thought that the time was coming for us to finally get answers.
“It’s difficult to find the words to describe what’s happened over the last few days. The most important thing should have been to establish how two young mums died and how their children have been left without their mummies. However, instead it feels like the Trust has been more focused on protecting itself.
“The hardest thing to accept is that these legal arguments should have been concluded way in advance of this week but instead the Trust submitted a request on the eve of the hearing and on a non-working day.
“While we now have to wait for the inquest, I’ll continue to fight to ensure I can at least get the answers I deserve as to why Kim died and also so that I can explain to her children when they’re older what happened to her.”
Speaking in court today, Dr Anton Van Dellen, who is representing Mrs Mulcahy's mother Nicola Foster, said the actions of the trust and the subsequent delay had "significantly impacted" the family's distress.
He said: "My client could have taken the easy course, and said 'yes I agree, have your anonymity, let’s hear the inquest'. She hasn’t taken that, she wants the inquest to be conducted properly and lawfully, and for the issues to be rightly examined.
"[The trust's] conduct has been disgraceful. They have caused the loss of this listing, the fruitless attendance of witnesses, and impacted on other families because the new listing will move back [other] inquests.
"She is extremely grateful to the press, for having allowed her to make contact with Kim's family, and she is very grateful for the support the family have given to herself and her family."
Anna Vroobel, the specialist medical negligence lawyer at Irwin Mitchell representing Kim’s family, said: “After nearly five years, Yvette really hoped that she would finally be able to receive the answers she deserves as to why Kim died.
“Understandably Yvette and the rest of Kim’s family are upset and frustrated by the events of the last few days especially as three previous pre-inquest review hearings were held at which these issues could have been discussed and agreed.
“They also follow on from the findings of the Kirkup review into maternity failings at East Kent Hospitals which, among other things, found that the Trust didn’t acknowledge problems, but instead was concerned about reputation management. Transparency is key to upholding public confidence in the health service.
“While this adjournment delays Kim’s family’s wait for answers, they accept it’s now necessary to ensure that the inquest isn’t rushed and that the most thorough and fearless investigation into the circumstances surrounding Kim’s death is conducted before a conclusion is reached.
“Understandably Yvette and the rest of her family continue to be profoundly affected by Kim’s death which happened in such tragic circumstances. We continue to support Yvette at this distressing time to ensure she gets the answers she deserves.”
"Bright and bubbly" barber Kim, who was already mum to a three-year-old daughter when she became pregnant again, lived with her mother in Newton Road, Whitstable.
After a smooth pregnancy, she went into labour at the QEQM Hospital in Margate on May 3, 2018. She experienced complications, and it was eventually decided to perform a C-section.
Baby Albie was delivered healthy, but Kim 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 Kim 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 Kim's baby.
"The most important thing should have been to establish how two young mums died..."
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 Kimberley, 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 Kimberley 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.
A spokeswoman for East Kent Hospitals said: “We apologise for the further delay and the ongoing distress this has caused the families of Kimberley and Samantha.”