The twins' father now has to bring up 11 children on his own
A coroner has said that neglect played a part in the death of a mother of 11 children, who died in hospital hours after having twins.
Somalia-born Ifrah Hureh, 38, from Adamsdown, Cardiff, died in 2008 at the University Hospital of Wales after pre-eclampsia symptoms were ignored.
Cardiff coroner Mary Hassell said there was "a gross failure to provide basic medical attention".
She recorded a verdict of natural causes contributed to by neglect.
The coroner has been told that since the death in March 2008, there had been many changes in procedures.
This investigation uncovered deficiencies in the care we provided to Mrs Hureh and helped us identify changes to our systems and practices to reduce the risk of such a sad event happening again
Sue Gregory, Cardiff and Vale NHS Trust
Ms Hassell said Mrs Hureh died of a large intracranial haemorrhage, caused by pre-eclampsia and Syntometrine - which is used to stimulate the womb to contract and help the delivery of the placenta, but which should not be used on patients with high blood pressure.
She said: "All the opportunities that were not taken up to recognise her high blood pressure culminated in what has been described to me as a critical and unforgivable error of giving her Syntometrine.
"Those treating Ifrah know that Syntometrine should not be given to a woman suffering from pre-eclampsia.
"Nevertheless, they gave her Syntometrine because they didn't recognise the pre-eclampsia and didn't check again immediately before giving as to whether it was contra-indicated.
Ifrah Hureh already had nine older children
"The plan to give Syntometrine had been made some weeks earlier, but this had not be reviewed immediately before the drug was administered."
The coroner explained the legal definition of neglect was a gross failure to provide basic medical attention.
"Although I recognise that some parts of Ifrah's care were very good and that everyone looking after Ifrah wanted the best for her, in some aspects there was a gross failure to provide basic medical attention," she added.
The coroner had asked a consultant to examine the case.
Giving expert evidence on the second day of the hearing, consultant obstetrician Patrick Forbes said the first failure in Mrs Hureh's case was not recognising that she had significantly abnormal blood pressure when she was admitted to the delivery suite.
The second was in giving the mother a drug which had the effect of raising her blood pressure, something which Mr Forbes said was a "critical and unforgivable error"
The third mistake, he said, was the failure to respond to a high blood pressure reading an hour after she had given birth.
He said even at that stage it would have been possible to bring Mrs Hureh's blood pressure down and avoid the fatal bleeding in her brain which occurred about two and a half hours later.
The inquest has previously heard evidence from hospital staff of failure in the mother's care.
Senior midwife Bernadette Moss, when questioned by the coroner, acknowledged the failure in basic medical attention received by Mrs Hureh was "gross".
The inquest heard Mrs Hureh was found to have raised blood pressure and high levels of protein in her urine - both symptoms of pre-eclampsia - while on the maternity ward.
Had the high blood pressure been acknowledged appropriately, Mrs Hureh would also not have been administered Syntometrine.
Another midwife Sylvia Castello, who admitted failing to recognise the raised blood pressure, told the inquest she had not been feeling well during her shift and not concentrating properly.
She apologised to Mrs Hureh's family, including her husband Ibrahim Yassin.
Midwife Louise Protheroe Davies said she forgot to send a urine sample for testing and failed to take hourly blood pressure tests after the birth.
About three hours later Mrs Hureh deteriorated and urgent medical attention was called for, the inquest heard.
Consultant obstetrician Audrey Long also told the inquest Mrs Hureh did not receive "appropriate care."
She said she would have expected the high blood pressure readings to be brought to her attention by the midwives monitoring Mrs Hureh, but it was not done.
Ms Hassell asked Ms Long: "Was it that you were so taken up with a woman who was high risk with her babies that you took your eye off the ball regarding her?"
The consultant, who now works in Stoke-on-Trent, replied: "I think so."
The coroner has been told that Mrs Hureh's case has led to many changes in procedures at the hospital and is included in a new training course for midwives and doctors.
After the inquest, Sue Gregory, nurse director of Cardiff and Vale NHS Trust said they were "very saddened" at Mrs Hureh's untimely death, had offered their apologies to her family and had carried out an internal investigation.
"This investigation uncovered deficiencies in the care we provided to Mrs Hureh and helped us identify changes to our systems and practices to reduce the risk of such a sad event happening again," she said.
"We now also ensure our midwives undertake specialist training to help identify and treat critically ill women.
"We would like to reassure Mr Yassin and the public that we have learned from this incident, and improvements have been made in the women's unit as a result."
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