A family was left heartbroken when a pregnant woman collapsed and died and doctors could not save her tiny son she never got to meet.
Laura Barnes, 22, suddenly collapsed in May 2022 as a result of a pulmonary embolism. She gave birth via an emergency caesarean section to Dexter but tragically never regained consciousness. In another tragedy for her family, the tiny baby passed away two months after his mother.
An inquest into the young mum’s death heard she was 15 weeks pregnant when she was first admitted to the Royal Blackburn Hospital in January 2022. She was diagnosed as having a clot in a vessel within her skull and was started on tinzaparin, an anti-coagulant which is used to treat deep venous thrombosis and prevent blood clots from forming.
However, the hearing at Preston Coroner's Court heard she was not given the correct dose of medication and there was no evidence suggesting Laura was weighed in order to determine the correct dose.
Dr Sarah Davies admitted there were several "significant failings" in Laura's care, which described as "disappointing and frustrating". When asked by senior coroner Dr James Adeley how she felt, she added: “Disappointing... I feel we let Laura down. I found out afterwards Laura had fainted during one of the blood tests. The message about the importance of it going to the lab wasn't relayed.” When asked if it was a failure, she replied "Yes."
After Laura collapsed on May 29 2022, her unborn baby was delivered via emergency caesarean section. Two months after Laura's death, Dexter tragically died while he was sleeping in his dad's bed alongside his 14-month-old brother. Laura's mum, Jennifer, who lives in Barrow-in-Furness, said there had been several errors in her daughter's care. She said it was heartbreaking Laura never met Dexter.
Professor Charles Hay, a consultant in haematology at Manchester Royal Infirmary, examined Laura's records and said Laura was 15 to 30 times at greater risk of developing a blood clot. However, he added that if Laura had been correctly anti-coagulated she would not have suffered the second clot which caused her death.
Since Laura's death all women requiring blood tests to ascertain anti-coagulation levels have had to travel to Manchester. East Lancashire Hospitals NHS Foundation Trust (ELHT) has plans to create a team locally but it is not yet fully-staffed despite almost two years having passed since Laura died.
Dr Adeley said he was highly concerned ELHT is considering reintroducing a system whereby anti-coagulation level testing is done in-house. He said: "The fact you are even thinking about reactivating this on the basis of half-baked documentation... You are either going to let me know this service is suspended until everything is checked out or you are going to get a Prevention of Future Deaths report."
Returning a narrative conclusion, Dr Adeley said: "The fact the treating consultant was unaware that eight out of nine tests failed shows that this system was a complete failure. The way in which the monitoring was carried out in this case... it is not even vaguely fit for purpose. "Even when it did produce a result this was not acted upon. Any system such as this is unfit for purpose and any system which resembles it in the future has my gravest concerns."
