Denaby Woman’s Death – Patient Left Too Soon – Coroner on Midwife Duties

July 1927

Mexborough and Swinton Times July 22, 1927

Denaby Woman’s Death
Patient Left Too Soon
Coroner on Midwife Duties

An inquest was held at the Denaby Main Institute on Tuesday by Mr Frank Allen into the death of Annie Hartley, aged 27, wife of William Hartley, miner of 75 Doncaster Rd, Denaby.

William Hartley identified the body as that of his wife, and said she was confined on Sunday about 3:30 AM. She was attended by a midwife who left about 5 AM. His wife appeared normal until about 6 AM when she became ill. He obtained the assistance of a neighbour, went for the midwife and a doctor.

Mrs Hadfield of 6 Strafford Terrace, Denaby Main, said she was a certified midwife and attended Mrs Hartley. She had not been previously engaged, was called at a minutes notice. She attended to deceased, and left there after about an hour. There was another woman in the room. Everything appeared satisfactory when witness left. She was called again and arrived a few minutes before 7 AM. Deceased was dead, and she tried artificial respiration.

Dr Georgie Mitchell, assistant to Dr MacArthur, said he had never previously attended Mrs Hartley. He was called a few minutes before 7 AM on Sunday, and when he arrived Mrs Hartley was dead.

The Coroner: Do you think the woman should have have been left without any experienced person after an hour’s attendance?

Dr Mitchell: Yes, if everything was normal.

Coroner: If you had attended this woman for the confinement, would you have left her after an hour?

Yes, if everything was satisfactory.

Do you think these people know whether their patient is fit or not?

That is a matter of opinion.

If you had seen signs of haemorrhage you would have been able to stop it? – Yes

The Coroner: It is a life lost that should have been saved. My point is that someone should have been there who was experienced. You say that haemorrhage may not occur for two hours, yet people are left after one hours. The number of cases fatal to the mother is about 3%, and if they all received proper attention it would be about 1%. We are up against a brick wall. In my idea no confinement should take place without the presence of a doctor. Had you been there you could have saved this woman’s life. Don’t you think so?

Yes I do.

In reply to coroner, Hartley said they had had five children, four living.

The Coroner said there ought to be continuous supervision for about 12 hours

Dr Mitchell: Yes, certainly

the coroner: and also inspections. A woman might bleed to death and no 1p wiser. If it is the custom for these midwives and their 10 a confinement to leave at a time when they think all is satisfactory there should be someone else left in charge.

A verdict of death from “Natural Causes” was returned.

The Coroner: I don’t say that anyone is to blame, and I don’t intend to express an opinion except that it seems to me that 75% of the midwives in the district like this – I can’t attempt to pull up the whole profession root and branch – appear to leave cases when everything seems satisfactory. I do think it ought to be part of the general duty to see that there is someone left in charge.

I am not censoring Mrs Hadfield