A woman who died giving birth to her stillborn daughter was given eight times the recommended dose of a labour–inducing drug – which experts say may have contributed to her death.
Jacqui Hunter, from Fowlis near Perth in Scotland, had been 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 deliver her the next day.
What the 39–year–old wasn’t told was that staff at Ninewells Hospital in Dundee gave her eight times the recommended dose of misoprostol needed to induce labour.
She endured a painful, protracted labour with intense contractions before collapsing into her husband’s arms, entering cardiac arrest.
Doctors worked rapidly to deliver Olivia by C-section in order to give Ms Hunter the best chance of survival Within hours, she was dead. Her husband, Lori–Mark Quate, lost his daughter and wife in the space of 24 hours.
A fatal accident inquiry – Scotland’s equivalent of a coroner’s inquest – ruled that she died of an 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) against a recommended 50mcg – had a role to play.
Misoprostol is known to increase the risk of AFEs because the drug can cause severe contractions that may force amniotic fluid into the mother’s bloodstream. Neither Mr Quate nor his wife were told of the error – despite medics being aware.
Jacqui Hunter pictured at home among the baby–gros picked out for Olivia before tragedy struck. She died giving birth to Olivia stillborn
Jacqui (pictured building her baby’s crib at home) was given eight times the recommended dose of a drug used to induce labour. The medication has a known link with increased risk of amniotic fluid embolism
Lori–Mark Quate, Jacqui’s husband, believes the overdose played a role in her death that has been played down (pictured with Lori)
While he will never have all of the answers as to how his wife died, he believes she may have had a fighting chance had she been told she had been given too much.
‘In Jacqui’s medical notes, there is no mention of that drug at all, at any point, until after she’s declared dead and passed,’ he told BBC Disclosure.
‘Not going to Jacqui, their patient, and saying ‘we have messed up’… there would have been opportunity to have removed that drug.
‘It may not have altered events going forward, but it might have and it’s a decision Jacqui should have been given.’
A 2020 review conducted by NHS Tayside, the health board in charge of Ninewells Hospital, acknowledged that the ‘incorrect dose must be considered as a major contributing factor to (Jacqui’s) AFE and subsequent death’.
The subsequent fatal accident inquiry hear from a consultant obstetrician, Dr Philip Owen, who said it was ‘possible but not probable’ that the overdose contributed to her death.
Sheriff Jillian Martin-Brown ultimately made no ruling on whether the overdose or whether failing to tell Ms Hunter had told her about the overdose, which Mr Quate declared a ‘whitewash’.
In a statement to the Daily Mail, NHS Tayside said it acknowledged that the deaths of Ms Hunter and Olivia were ‘devastating’ and that it was ‘so deeply sorry’ for their losses.
A spokesperson for the health board added: ‘NHS Tayside undertook a number of internal investigations and engaged in external reviews following the deaths to ensure all learning opportunities were taken by the organisation to deliver improvements.
‘All recommendations identified in the reviews were fully accepted and, as a result, our systems and processes have been strengthened where required and improvements have been made to how we provide care.’
The tragedy has shone a light on what experts say is a growing problem with maternity care in Scotland, where two significant spikes in deaths among newborn babies in 2021/22 prompted a national review.
Lori–Mark Quate spoke to BBC Disclosure about what he felt were the failings to prevent his wife’s death on a maternity ward
The overdose playing a role in Ms Hunter’s death was ‘possible, not probable’, a fatal accident inquiry later heard
Lori-Mark Quate and Jacqui Hunter pictured together. He later branded his wife’s fatal accident inquiry a ‘whitewash’
The fatal procedure was undertaken at Ninewells Hospital in Dundee (pictured), which has since been the subject of Scotland’s first dedicated maternity service inspection
Healthcare Improvement Scotland found that health boards were carrying out reviews of varying quality following neonatal deaths, meaning learning opportunities were being missed.
Its findings prompted a government–commissioned review of neonatal deaths, which concluded last year, and the commissioning of independent inspections of Scottish maternity units.
At Ninewells, where Ms Hunter died, Healthcare Improvement Scotland (HIS) inspectors issued 20 requirements for improvement in May last year after making troubling findings.
They found that the maternity unit was short–staffed, workers were unsure of where to find emergency medication, expectant mothers were waiting up to 72 hours to have labour induced and fetal heartbeat monitors were missing vital cables.
NHS Tayside said of the HIS visit: ‘The focus of the inspection was different from the reviews following Ms Hunter and Olivia’s death.
‘The HIS report identified areas for learning and improvement and also highlighted where our teams were delivering sensitive, responsive, and high–quality care.
‘NHS Tayside is committed to providing safe, compassionate, and high–quality services to women and families in our care.
‘We also remain committed to continuously learning and improving so that we can offer the best possible support to every family we serve.’
Experts told the BBC that they believed health boards were failing to learn from infant deaths, even after significant adverse event reviews (SAERs) that are commissioned following unexpected or avoidable deaths in care.
Dr Helen Mactier has expressed concern over whether reviews after neonatal deaths are leading to any real change in the health service
Parents Julie and Angus lost their son Mason Scott McLean at the age of just three days
Julie and Angus have expressed concern over whether health boards will learn lessons from reviews meant to prevent further deaths
Parents Julie and Angus’ son Mason Scott McLean died at just three days old after developing sepsis.
He had developed hypothermia but equipment to warm him up was not sourced after they took him to the Royal Hospital for Children in Glasgow.
Mr and Mrs McLean say staff failed to grasp the seriousness of his condition before he passed. Tests were not carried out to ascertain his condition.
‘You just think, are the mistakes going to happen again?’ Julie asked.
Just 143 SAERs have been held in Scotland since 2020 – while 613 equivalent reviews were conducted in England between April 2024 and March 2025 alone.
Dr Helen Mactier, who wrote the review of neonatal deaths published last year, said: ‘It’s very concerning that review after review says essentially the same thing. It says that we commonly fail to listen to patients.’
The Scottish Government says it has made ‘significant progress’ in reducing infant mortality, and that it is committed to learning from unexpected deaths.
Jenni Minto, public health minister, told the BBC: ‘We are committed to learning from every case to improve care, strengthen safety, and support women and their families.’
- BBC Disclosure: How Safe Is My Baby? is on BBC One Scotland tonight at 8pm, and can be watched on iPlayer now.
