Kimberley Sampson and Samantha Mulcahy

Date of report	17 Sep 2023
Reference	2023-0338
Deceased	Kimberley Sampson and Samantha Mulcahy
Coroner	Catherine Wood
Coroner area	Central and South East Kent
Category	Hospital Death (Clinical Procedures and medical management) related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

2. 

1 

CORONER 

, President, Royal College of Obstetricians &Gynaecologists 

, Chief Executive NHS England 

I am Catherine Wood, assistant coroner, for the coroner area of Central and South East 
Kent. 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 

http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATIONS and INQUESTS 

An investigation into the deaths of Kimberley Sampson who died on 22 May 2018 and 
Samantha Mulcahy who died on 4 July 2019 both from herpes simplex infections initially 
led to a discontinuation of both investigations on 2 October 2019. The investigations 
were reopened on 4 January 2022 as concerns were raised about a possible common 
source of infection. The investigations concluded at the end of the inquests which were 
held jointly and final conclusions handed down on 26 July 2023. 

The cause of death for both young women determined at the inquests was: 
1a) Multi- Organ Failure 
1b) Disseminated Herpes Simplex type I infection 
1c) Herpes Simplex virus acquired before or around the time of delivery 
2. Third trimester pregnancy 

A narrative conclusion was reached in both inquests and both narratives are set out 
below: 

“Kimberly Sampson died as a consequence of disseminated Herpes Simplex 1 infection 
with the initial infection having been acquired before or around the time of the delivery of 
her baby. There was a delay in instituting antiviral therapy, the known treatment for her 
illness, due in part to the presence of a concurrent bacterial infection but also due to a 
delay in recognising and linking the cause of her deteriorating liver function as being a 
symptom of a viral infection.” 

“Samantha Mulcahy died as a consequence of disseminated Herpes Simplex 1 infection 
with the initial infection having been acquired before or around the time of the delivery of 
her baby. Antiviral therapy, the known treatment for her illness, was not instituted as her 
symptoms were unclear and her previous obstetric cholestasis had complicated the 
picture.” 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 

CIRCUMSTANCES OF THE DEATHS 

The circumstances in relation to Kimberley Sampson’s death were that she had been fit 
and well when she became pregnant in 2017. She underwent a caesarean section for 
failure to progress on 3 May 2018 which was complicated by some bleeding. She went 
home on 5 May 2018 but was readmitted to Queen Elizabeth the Queen Mother hospital 
on 10 May 2018 with signs of sepsis and she was treated with broad spectrum 
intravenous antibiotics. An abdominal collection was drained on 12 May 2018 by way of 
a laparotomy. Some samples sent to the laboratory had grown gram positive bacteria 
and she was treated and her antibiotics were adjusted. She became more unwell on 16 
May 2018 and her liver was showing signs of failure and a further laparotomy was 
performed which was essentially negative.  She continued to deteriorate and by 18 May 
2018 discussions were held with Kings College hospital and advice given by them to 
commence Acyclovir and she was transferred to Kings College hospital liver unit the 
following day. By this stage she was 16 days post delivery and showing signs of multiple 
organ failure with cardiovascular instability, respiratory and liver failure as well as a 
severe coagulopathy and signs of acute kidney injury. Despite full resuscitative 
measures including ECMO she died from multiple organ failure as a consequence of her 
disseminated herpes simplex infection on 22 May 2018. 

The circumstances in relation to Samantha Mulcahy’s death occurred very shortly after 
the death of Kimberley Sampson and clinicians in common were involved in looking after 
both mothers. I found that their index of suspicion should have been raised and indeed a 
viral cause and possible treatment was suggested by one Obstetrician but following a 
discussion with a Microbiologist was not instituted. 

Samantha Mulcahy had a past medical history of oesophageal hernia, polycystic 
ovaries, gallstones and underactive thyroid when she became pregnant in 2017. She 
developed obstetric cholestasis in the latter stages of her pregnancy and required a 
caesarean section for failure to progress on 26 June 2018 which was complicated by a 
tear to the broad ligament. On 28 June she developed signs of sepsis and was 
commenced on broad spectrum intravenous antibiotics. She did not improve and her 
respiratory function deteriorated and investigations including a CTPA on undertaken to 
rule out a pulmonary embolism as a cause of her symptoms. Antiviral medication was 
discussed by the obstetrician and microbiologist on 30 June 2018 but a decision made 
that it should not be commenced. She was transferred to Intensive care unit on the 
morning of the 30 June and she was considered to be suffering from respiratory failure 
secondary to abdominal distension with a possible pneumonia and she improved slightly 
over the course of the day with treatment. A CTPA was undertaken on 2 July 2018 to 
rule out a pulmonary embolism as a cause of her symptoms which showed no PE but 
some patchy shadowing in her lungs and bilateral pleural effusions. She deteriorated 
significantly overnight between the 2 and 3 July 2018 with a decrease in urine output 
and her liver function tests the next morning showed fulminant liver failure and she had 
also developed ascites. There was a delay in recognising a viral cause of her illness as it 
was thought that she may be suffering from steatosis plus sepsis and discussions with 
the liver unit at Kings College hospital led to recommendations to commence antifungal 
not antiviral medication. She continued to deteriorate and discussions were held about 
ECMO with the team arriving around 2am on 4 July 2018. She was transferred to 
theatres to set up ECMO and operate if necessary. Despite all attempts to improve her 
situation she continued to deteriorate and died around 07.15 that morning. 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 The MATTERS OF CONCERN are as follows.  – 

(1)  The inquest heard evidence of steps having been taken to try to establish if the 

deaths of both women were linked and if there was a common source of 
infection. In both inquests the women had been treated in separate hospitals but 
within the same Trust and two members of staff had been involved in treating 
both women. The inquest heard that Public Health England were involved in the 
investigation following the deaths and advice on testing staff was unclear which 
meant neither of the members of staff involved with both women were tested. 
The inquest was however unable to establish if the strain of the virus was the 
same in both women as the evidence on this was inconsistent and on balance 
the evidence did not support a conclusion that both women were infected by the 
same source. 

(2)  Evidence given at the inquest revealed that Herpes Simplex can be fatal if 

contracted in pregnancy and whilst deaths are rare there is no specific guidance 
in relation to treating women in the post-partum period with anti-viral therapy. It 
was accepted by all who gave evidence that antiviral medication would have 
been the recognised treatment for Herpes Simplex (specifically Acyclovir). The 
Trust has made some minor amendments to its protocols but there is no 
national guidance either in place back in 2018 or currently in 2023 on 
prescribing antiviral medication to women who present with signs of systemic 
infection. Had Acyclovir been prescribed at an earlier stage it is likely to have 
significantly reduced the risk of death from progression of the disease. Sepsis 
protocols cover antibiotic therapy but not antiviral therapy. What was abundantly 
clear from the evidence before the court was that this is a rare but often fatal 
disease if contracted in the peripartum period and more needs to be done to 
raise awareness of it as a potential diagnosis to exclude in sepsis pathways and 
for early consideration of the use to Acyclovir. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 12 November 2023.  I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons namely the families, and East Kent Hospitals University NHS Foundation Trust. 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 9 

17 September 2023 

Catherine Wood 
Assistant Coroner 
Central and South East Kent

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from NHS England (PDF)

Catherine Wood 
Central and South East Kent Coroner Service 
Cantium House 
Sandling Road 
Maidstone 
ME14 1XD 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

11 December 2023  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Kimberley Sampson who 
died on 22 May 2018 and Samantha Mulcahy who died on 4 July 2019.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  17 
September  2023  concerning  the  deaths  of  Kimberley  Sampson  and  Samantha 
Mulcahy. In advance of responding to the specific concerns raised in your Report, I 
would like to express my deep condolences to Kimberley’s and Samantha’s family and 
loved  ones.  NHS  England  are  keen  to  assure  the  family  and  the  coroner  that  the 
concerns raised about the care that Kimberley and Samantha have received has been 
listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  to  Kimberley’s  and  Samantha’s  family  or 
friends.  I  realise  that  responses  to  Coroner  Reports  can  form  part  of  the  important 
process of family and friends coming to terms with what has happened to their loved 
ones and appreciate this will have been an incredibly difficult time for them. 

Strain of Herpes Simplex Virus contracted by Kimberley and Samantha 

The first matter of concern in your Report was that the inquest was unable to establish 
if the strain of Herpes Simplex 1 infection suffered by both Kimberley and Samantha 
was  of  the  same  strain  and  came  from  the  same  source  and  that  the  evidence  on 
whether this was the case was inconsistent.  

NHS  England  are  not  the  appropriate  organisation  to  provide  comment  on  any 
investigation into the source of Herpes Simplex Virus (HSV) 1 infection contracted by 
Kimberley and Samantha. You may wish to refer this matter of concern to East Kent 
Hospitals University NHS Foundation Trust (hereafter “the Trust”) or to the UK Health 
Security  Agency  (UKHSA),  who  assumed  many  of  the  public  health  and  health 
protection responsibilities following the disbandment of Public Health England (PHE) 
in October 2021.  

NHS England has however engaged with UKHSA and the Trust following receipt of 
your  Report.  We  have  been  sighted  on  a  letter  sent  from  PHE  to  the  Trust  on  12 
September  2018,  following  phylogenetic  analysis  of  the  HSV  samples  that  were 
provided  to  them  following  the  deaths  of  Kimberley  and  Samantha.  NHS  England 
notes PHE’s findings that while the sequences within both samples are identical, due 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 to the evolutionary rate of HSV this does not mean that the virus will have the same 
common source or that they are part of a transmission chain.  

NHS England also understands that the Trust has taken on board recommendations 
and implemented several actions following investigations into the deaths of Kimberley 
and Samantha and have been sighted on the Trust’s Improvement Plans. Actions have 
included developing guidance for women and their families about HSV which has been 
added  to  postnatal  discharge  leaflets  and  a  full  Infection  Prevention  Control  (IPC) 
review within the Trust which has included ensuring staff are aware of IPC guidelines 
related to HSV  infections as well as sharing learnings from these cases across the 
Trust.  

National  guidance  for  prescribing  antiviral  medication  for  postpartum  women 
who present with signs of systemic infection 

Your  second  concern  related  to  the  delays  in  prescribing  the  antiviral  medication 
Acyclovir  to  Kimberley  and  Samantha  and  that  there  was  no  national  guidance  in 
relation to prescribing antiviral medication in such cases, and that more needed to be 
done to raise awareness of the possibility of HSV to exclude in sepsis pathways.  

The relevant national guidance does not come under the remit of NHS England. The 
Royal College of Obstetricians & Gynaecologists (RCOG), who you also addressed 
your Report to, are one of the organisations responsible for the national guidance on 
diagnosing and treating sepsis during pregnancy and we note their response to you 
that  they  are  in  the  process  of  updating  their  Green-top  Guidelines  on  Sepsis  in 
pregnancy (No. 64a) and Bacterial sepsis following pregnancy (No. 64b). The update 
will  result  in  a  new  combined  guideline  titled  Identification  and  management  of 
maternal sepsis during and following pregnancy (No. 64), which will include guidance 
on the timely and routine identification and treatment of herpes simplex. NHS England 
notes that this is scheduled for publication in March 2024.  

The  UK  National  Screening  Committee  (UK  NSC)  does  not  currently  recommend 
screening for genital herpes in pregnant women. This is because it is not known how 
many women in the UK are infected with HSV-1 and HSV-2, how accurate screening 
tests  are  in  pregnant  women,  how  effective  treatments  are  to  stop  women  passing 
HSV to their babies and how effective treatments are to stop pregnant women from 
catching the disease.  

NHS England notes some of the actions included in the Trust’s Improvement Plans, 
which have included implementation of a new HSV-1 pathway with the aim to improve 
early diagnosis and teaching of care of deteriorating women within their Skills Update 
in  Maternity  (SUM)  training  day,  which  includes  Modified  Early  Obstetric  Warning 
(MEOW) scores and necessary escalations.  

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 

 
 
 
 a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

Response from Royal College of Obstetricians and Gynaecologists (PDF)

Catherine Wood
Assistant Coroner
Central and South East Kent

10 November 2023

Dear Ms Wood,

Re: Samantha Mulcahy– deceased
Re: Kimberley Sampson– deceased

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into
the deaths of Samantha Mulcahy and Kimberley Sampson dated 19th September 2023.

The loss of a young woman is a devastating tragedy for the wider family and healthcare
professionals involved. We would like to begin by extending our deepest and heartfelt
condolences to Samantha and Kimberley’s family for their deep loss.

This response has been developed following input from members of the RCOG Patient
Safety Committee and Senior Officers of the College.

We recognise and respect the narrative conclusion from the inquest that Samantha and
Kimberley died as a result of

1a.Multi-organ failure
1b. Disseminated Herpes Simplex 1 Infection
1c. Herpes simplex virus acquired before or around the time of delivery
2. Third trimester pregnancy

We also recognise the matters of concern, in particular concern 2;

Evidence given at the inquest revealed that Herpes Simplex can be fatal if contracted in
pregnancy and whilst deaths are rare there is no specific guidance in relation to treating
women in the post-partum period with anti-viral therapy. It was accepted by all who gave
evidence that antiviral medication would have been the recognised treatment for Herpes
Simplex (specifically Acyclovir). The Trust has made some minor amendments to its
protocols but there is no national guidance either in place back in 2018 or currently in
2023 on prescribing antiviral medication to women who present with signs of systemic
infection. Had Acyclovir been prescribed at an earlier stage it is likely to have significantly
reduced the risk of death from progression of the disease. Sepsis protocols cover antibiotic
therapy but not antiviral therapy. What was abundantly clear from the evidence before
the court was that this is a rare but often fatal disease if contracted in the peripartum

Page 1 of 2

period and more needs to be done to raise awareness of it as a potential diagnosis to
exclude in sepsis pathways and for early consideration of the use to Acyclovir.

The College is currently in the process of updating its Green-top Guidelines on Sepsis in
pregnancy (No. 64a) and Bacterial sepsis following pregnancy (No. 64b). The new name of
the combined guideline will be Identification and management of maternal sepsis during
and following pregnancy (No. 64). We will ensure that this updated version will contain
guidance on the timely identification and treatment of herpes simplex. This is currently
scheduled for publication in March 2024.

The RCOG is committed to improving the standard of care provided for women by working
collaboratively with all stakeholders, including Coroners.

Yours faithfully,

CEO Royal College of Obstetricians and Gynaecologists

Page 2 of 2

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