A coroner has issued two Prevention of Future Deaths reports following the death of a first-time mother weeks after giving birth.

 A new mother died after important checks were not carried out at her final antenatal appointment, an inquest has heard.

During the appointment, the 30-year-old’s blood pressure was raised, and a scan showed her baby’s growth had slowed. Despite this, the blood pressure check was not repeated, and the woman’s urine was not tested for protein, a warning sign of pre-eclampsia.

Penelope Schofield, senior coroner for West Sussex, Brighton and Hove, concluded that further investigations should have been carried out on the woman, who was 36 weeks and three days pregnant at the time. Blood tests may have identified abnormal liver function and led to the woman being admitted to hospital earlier, Schofield found.

However, during the five-day inquest held last month, Schofield could not establish whether earlier admission would have prevented her death.

The coroner concluded that the woman died from natural causes after multi-organ failure, severe acute necrotising pancreatitis, a life-threatening inflammation of the pancreas, and acute fatty liver of pregnancy, a rare, serious liver condition.

Two days after the appointment, the woman, from Hove, was admitted to Worthing Hospital severely unwell with severely abnormal liver and kidney results. Her daughter was born by emergency caesarean section that day.

Condition deteriorates

Remaining critically ill, the patient was transferred to the ICU at Royal Sussex Hospital in Brighton, where she developed sepsis, liver dysfunction and problems with her caesarean section wound. Her condition further deteriorated as she began bleeding internally.

She had an operation to block the bleeding vessel and was then transferred to the Royal Surrey County Hospital in Guildford, where she underwent emergency surgery. Doctors later concluded there were no further surgical options. The new mother died on June 13, seven weeks after her daughter was born.

Following the inquest, Schofield will issue two Prevention of Future Deaths (PFD) reports. One will address the oversights during the antenatal appointment, while the second will concern communication issues between the hospitals involved in her later care.

Commenting on the findings, Bill Jewsbury, medical director of Royal Surrey NHS Foundation Trust, said he recognised that communication between the two hospitals “presented challenges”.

“We are committed to improving this through embedding a new and more robust system,” he said.

He added that the trust’s care was not criticised by the coroner.

Katie Urch, chief medical officer for University Hospitals Sussex NHS Foundation Trust, which is in charge of the Royal Sussex and Worthing hospitals, said the trust would respond to the PFD “fully and as a matter of urgency”.

Urch added that the coroner found no omissions in the trust’s care were likely to have changed the outcome.