Coroner finds multiple failings at Gloucestershire Royal Hospital after tragic death of Rana Abdelkarim

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Novum Law has been supporting Modar Mohammednour this week at the inquest into the death of his wife, Rana Abdelkarim, who died shortly after giving birth to the couple’s second daughter at the Gloucestershire Royal Hospital on 8 March 2021.

Almost a year to the day that Rana, 38, lost her life after suffering a severe post-birth bleed (post-partum haemorrhage) in which she lost over 6 litres of blood, the coroner at Gloucestershire Coroner’s Court has concluded that there was a ‘number of failings’ in her treatment before, during and after she gave birth.

Despite a number of risk factors, including Female Genital Mutilation (FGM), Rana’s care was not escalated to a specialist obstetric team, and when her bleeding worsened and her condition deteriorated, there was confusion around the emergency call procedure, and the emergency call bell was not used to get help.

The coroner concluded that when Rana eventually received treatment for the postpartum haemorrhage (PPH) there were delays in how this was managed.

An earlier report into her death by the Healthcare Safety Investigation Branch (HSIB) found that guidelines for managing PPH were “not completely followed” and there was a delay in requesting and administering blood products, with the first transfusion starting 53 minutes after the ongoing bleeding.

The coroner also concluded that the hospital’s response to Rana’s haemorrhage focussed on the actual volume of blood loss, rather than the proportionate blood loss. In other words, hospital staff did not take into account Rana’s body weight and BMI which was at the lower end of the normal range and underestimated her blood loss.

The language barrier Rana and Modar, her husband faced was also highlighted by the coroner. Rana and Modar were from Sudan and spoke limited English.

When Rana went to Gloucestershire Royal Hospital, the couple was expecting a routine appointment, but instead, she was induced without proper consent being given. Modar stayed at home looking after their other child, completely unaware of the ordeal Rana was going through.

After HM Coroner Katy Skerret delivered her narrative conclusion, Solicitor Hannah Carr, who specialises in women’s health and medical negligence, and represents Modar Mohammednour and his family, said:

“What is clear is that Gloucestershire Hospitals NHS Foundation Trust failed Rana Abdelkarim, her husband, Modar, and their two young daughters, Reem and Rana. 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.

“The couple spoke limited English and did not understand Rana was going into the hospital to be induced. The lack of interpretation services meant that proper consent to induce labour was not given, Rana was admitted to the hospital without her husband there to support her and she was alone during labour, the birth of their baby and when she died. I cannot begin to imagine how terrified and alone Rana must have felt without any access to interpretation services and without her husband by her side.

“This week’s inquest is important because it is a harsh reality that black and minority ethnic women and families with social risk factors such as deprivation, refugee and asylum seeker status, homelessness, mental health issues and domestic violence are at a disproportionate risk of poor birth outcomes. Language barriers exacerbate this risk with women struggling to engage with maternity services and communicate their concerns to healthcare professionals.

“At Novum Law, we are working to ensure people are listened to and heard and are involved and informed throughout their treatment and care. Lessons need to be learned from what happened to Rana and it must never happen again.

“For Modar, while the Trust has taken steps to learn from Rana’s tragic death, it doesn’t change things for him and his family. That said, there is a sense of justice for him as he has always said he wanted to try and prevent this from happening to other families. He does however extend his thanks to the coroner and all those involved in the investigation into Rana’s death.

“We hope that today’s inquest results in ongoing training, support and analysis of the management of obstetric haemorrhage as well as ongoing work to ensure there are interpretation services are available for families who speak limited English, with opportunities to reflect and ensure there is appropriate understanding and consent to antenatal care.”

A tribute to Rana Abdelkarim

Modar describes Rana as a “really beautiful woman who made a good connection with everybody” and was a “really amazing person.” She was from a village in Sudan and came from a “great family” she was “very traditional and a great mother” and “everything a man would want in a wife.”

Speaking about how he is finding things bringing up his two girls on his own he says, “I have no life now. Just pain. I miss my wife so much and just feel pain in my life all the time.” He goes on sadly, “I tell my daughters she’s in paradise now.”

Media coverage of Rana’s case

Following the conclusion of the inquest on 7 March 2023, Hannah gave a statement on behalf of Modar which was aired on ITV News West Country and BBC Points West. You can view the footage here:


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