Mother-to-be died in childbirth after being given ‘overdose’ of labour-inducing drug following death of her unborn daughter in the womb

A woman who died giving birth to her stillborn daughter was given eight times the recommended dose of labor-inducing medication; experts say this may have contributed to the woman’s death.

Jacqui Hunter, from Fowlis, near Perth, Scotland, was given the devastating news in May 2020 that her daughter Olivia had died in the womb days before her due date and that she would be given medication to help with her birth the next day.

The 39-year-old was not told that staff at Ninewells Hospital in Dundee had given her eight times the dose of misoprostol needed to induce labour.

She endured a painful, prolonged labor with intense contractions before falling into her husband’s arms and suffering a heart attack.

Doctors worked quickly to deliver Olivia by Caesarean section to give Ms. Hunter the best chance of survival. Within a few hours the woman was dead. Her husband, Lori-Mark Quate, lost his daughter and wife within 24 hours.

A fatal accident inquest – Scotland’s equivalent of a coroner’s inquest – ruled that she died from amniotic fluid embolism (AFE), a severe allergic reaction to amniotic fluid in the bloodstream.

But Mr Quate believes the overdose of misoprostol (400 micrograms (mcg) versus the recommended 50 mcg) played a significant role.

Misoprostol is known to increase the risk of AFE because the drug can cause violent contractions that can force amniotic fluid into the mother’s bloodstream. Neither Mr Quate nor his wife were told of the error, although paramedics were aware of it.

Jacqui (pictured cribbing her baby at home) was given eight times the recommended dose of the drug used to induce labour. The drug has a known link to an increased risk of amniotic fluid embolism

Jacqui’s husband, Lori-Mark Quate, believes an overdose played a role in her death, but the role is downplayed (pictured with Lori)

Although he may never know all the answers to how his wife died, he believes she might have information about it. If he had been told he had been given too much, he would have had a fighting chance.

‘At no point in Jacqui’s medical notes is this medication mentioned until after she was declared dead and she passed away,’ he said BBC Statement.

‘If we hadn’t gone to his patient, Jacqui, and said, ‘We messed up,’ there would have been an opportunity to eliminate that drug.

‘It may not have changed events going forward, but it may have happened and that was a decision that should have been left to Jacqui.’

A review carried out in 2020 by NHS Tayside, the medical board responsible for Ninewells Hospital, acknowledged that ‘the incorrect dose should be considered a significant factor contributing to (Jacqui’s) AFE and subsequent death’.

At the subsequent fatal accident investigation, consultant obstetrician Dr. Philip Owen said it was ‘possible but unlikely’ that an overdose contributed to her death.

Sheriff Jillian Martin-Brown made no determination as to whether an overdose had occurred or whether Ms Hunter had been told about the overdose, with Mr Quate describing it as a ‘whitewash’.

In a statement to the Daily Mail, NHS Tayside acknowledged the deaths of Miss Hunter and Olivia were ‘devastating’ and expressed ‘deep sadness’ for their loss.

A spokesman for the health board added: ‘NHS Tayside has carried out a number of internal investigations and external reviews following the deaths to ensure all learning opportunities are used by the organization to drive improvements.

‘All recommendations identified in the reviews have been fully accepted and as a result our systems and processes have been strengthened where necessary and improvements have been made to the way we deliver care.’

The tragedy has highlighted a growing problem with maternity care in Scotland, where two significant increases in newborn deaths in 2021/22 have sparked a national review, experts say.

Lori–Mark Quate tells BBC Explained how he feels about failures to prevent his wife’s death in the maternity ward

A fatal accident inquest later ruled it was ‘possible, not likely’ that an overdose played a role in Ms Hunter’s death.

Lori-Mark Quate and Jacqui Hunter are in the photo together. He later called his wife’s fatal crash investigation a ‘whitewash’

The fatal procedure was carried out at Ninewells Hospital in Dundee (pictured), which has since become the subject of Scotland’s first private maternity service inspection.

Healthcare Improvement Scotland found that health boards are carrying out reviews of varying quality following neonatal deaths, meaning learning opportunities are being missed.

Its findings led to the completion last year of a government-commissioned neonatal death review and the launch of independent inspections of maternity units in Scotland.

At Ninewells, where Ms Hunter died, Improvement Health Services Scotland (HIS) inspectors issued 20 requirements for improvement in May last year after making troubling findings.

They discovered the maternity unit was understaffed, workers were unsure of where to find emergency medications, expectant mothers were waiting up to 72 hours for labor to be induced, and fetal heartbeat monitors were missing vital wires.

NHS Tayside said of the visit to HIS: ‘The focus of the inspection was different to the reviews carried out following the deaths of Miss Hunter and Olivia.

‘The HIS report identified areas for learning and improvement and also highlighted where our teams are sensitive, responsive and deliver high quality care.

‘NHS Tayside is committed to providing safe, compassionate and high-quality services to the women and families in our care.

‘We are also committed to continually learning and improving so that we can provide the best possible support to every family we serve.’

Experts have told the BBC they believe health boards have failed to learn the lessons of infant deaths, even after major adverse event reviews (SAERs) were put in place following unexpected or preventable deaths in care.

Dr Helen Mactier has expressed concern about whether investigations into the aftermath of neonatal deaths are leading to real change in healthcare

Parents Julie and Angus lost their son Mason Scott McLean when he was just three days old.

Julie and Angus raised concerns about whether health boards will learn from the reviews to prevent more deaths

Parents Julie and Angus’ son Mason Scott McLean died when he was just three days old after developing sepsis.

He had developed hypothermia but after taking him to the Royal Children’s Hospital in Glasgow, equipment to warm him could not be obtained.

Mr and Mrs McLean said staff were unable to understand the seriousness of his condition before he died. No tests were performed to determine his condition.

‘Think about it, will mistakes happen again?’ Julie asked.

Only 143 SAERs have been issued in Scotland since 2020; In the UK, 613 equivalent inspections were carried out between April 2024 and March 2025 alone.

Dr. wrote the review of neonatal deaths published last year. Helen Mactier said: ‘It is very worrying that the reviews are essentially saying the same thing. He says we often fail to listen to patients.’

The Scottish Government has said it has made ‘significant progress’ in reducing infant deaths and is determined to learn from unexpected deaths.

Public health minister Jenni Minto told the BBC: ‘We are determined to learn from every case to improve care, strengthen safety and support women and their families.’

• BBC Statement: How Safe is My Baby? It’s on BBC One Scotland tonight at 8pm and can be watched here: iPlayer Now.