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 suffered a ‘major’ bleed giving birth to Parker, who weighed 9lbs 2oz, losing almost four litres of blood.
As a result of the bleed, Teegan was starved of oxygen and suffered a severe brain injury and later died on October 7, 2019.
Parker was categorised as a macrosomic baby - one that is larger than the average baby.
West Sussex Coroner’s Court, in Chichester, heard that under local NHS guidelines, Teegan could have been offered an induced labour at 38 weeks - three weeks before she eventually gave birth.
Investigators from the Healthcare Safety Investigation Branch (HSIB) said it would have been ‘best practice’ to have offered the teenager an induced labour.
Instead, Teegan’s little boy grew in size and ‘in retrospect it would have contributed to the risk of postpartum haemorrhage (PPH)’.
Teegan’s heartbroken family said the youngster would have been ‘an absolutely fantastic mum’.
Speaking at the start of the four-day inquest in Chichester, her family said: ‘Teegan had a big personality and was full of life and loved her family,’ adding she had no major illness growing up.
Teegan was given ‘a lot of support’, medical staff insisted during the inquest into her death.
Sally Waters, Teegan’s community midwife, had dealt with the teenager throughout most her pregnancy and described it as ‘uncomplicated’.
She added: ‘She was poorly sometimes. But there were no abnormal complications.
‘With Teegan it wasn’t seen to be she was going to have a large baby… She plotted on the 90th percentile and that was all within the normal trend.
‘At that point when I was looking after her. I wasn’t expecting a big baby.’
At St Richard’s, Teegan suffered obstructive labour - when a baby cannot exit the pelvis - and she underwent a caesarean section.
She lost 3.85 litres of blood - almost eight times the average amount of blood lost during a normal birth.
Matt Mansbridge, lead investigator at the HSIB, told the court that Teegan then suffered difficulties breathing and was given ‘manual ventilation’.
He said: "Teegan was bleeding. There was a major haemorrhage.
"Due to the level of blood loss, Teegan was transferred to the high-dependency unit.
"Her lips became blue and an alarm sounded from the ventilator machines.
"There was resistance in the ventilation. There were initial checks undertaken to see if there was a blockage in the system before manual ventilation was attempted."
Debbie Laing, maternity investigations team leader at the HSIB, said it would have been ‘appropriate’ to have made a decision on inducing labour.
But she said that the investigative panel determined such a measure would have been undertaken for ‘foetal wellbeing not for maternal wellbeing’.
She said: "There was no finding on [obstructive labour] with the exception that had the baby been induced earlier it would have been smaller.
"That’s the only thing that may have had a causal effect on the outcome.
"We are able to say it would have been best practice to offer the induction earlier. It would have been down to Teegan and her family to make a decision as to whether it would have been done."
She added: "Had induction of labour been at 38 weeks that would have been in line with guidance and appropriate at that time. What we now know with retrospect is that the baby grew and that would have contributed to the risk of PPH."
Following her death, Teegan’s parents Abbie Hallawell and Trevor Barnard instructed expert medical negligence lawyers at Irwin Mitchell to help establish answers and support the family through the inquest process.
Abbie said: "Teegan and the rest of the family were delighted when she fell pregnant. She was really looking forward to becoming a parent and she would have been an absolutely fantastic mum.
"It still doesn’t really seem real that what should have been the best day in Teegan’s life ended tragically and left all of our family changed forever.
"It’s been more than two years since Teegan died but time has stood still for all our family. I know the inquest and listening to the evidence around Teegan’s death is going to be incredibly upsetting but it’s something I’ve got to do not only for Teegan, but also for Parker.
"Teegan would have been so proud of Parker and how he’s such a happy baby who’s developing every day. While he’ll grow up without his mum in his life he will always be told how much
"Teegan loved him and how she’ll always be a part of our family.’"
Abbie and Trevor are now bringing up Parker alongside his dad, Leon Forster.