Mum died amid blood clot failings after childbirth

A 22-year-old mother died after a series of failings meant she did not receive the right amount of medication to treat a blood clot after an emergency C-section, an inquest heard.

Laura Barnes, from Rishton, Lancashire, was 32 weeks pregnant with her second child when she collapsed at home on 29 May 2022.

Ms Barnes, who had been treated for a previous stroke, was given an emergency C-section at Royal Blackburn Hospital but died the same day from a blood clot on her lung.

Her son Dexter was successfully delivered but also died eight weeks later after being found unresponsive at his home in bed with his father and brother.

Ms Barnes was first admitted to the hospital after suffering a stroke in January 2022 and a CT scan discovered a blood clot in her brain.

She was given anti-coagulant medication called tinzaparin to reduce the clot, which her partner Shane Khan told the inquest either he or Ms Barnes would administer twice a day.

The dose is determined by the patient's weight but the inquest heard Ms Barnes, who was described as morbidly obese at 29.8 stone (189kg), was not weighed on the stroke unit before her dosage was calculated.

Dr Sarah Davies, Ms Barnes' consultant during her pregnancy, told the hearing that she requested regular monitoring of Ms Barnes' condition via blood tests carried out by hospital staff.

But only one out of the nine tests was successful and Dr Davies said she was unaware of these failings until another appointment with Ms Barnes six days before she died.

Not all the tests had been carried out due to appointment and equipment errors, the inquest heard.

Dr Davies said this was "disappointing", adding: "I feel that we’ve let Laura down. It’s a poor system, very poor.”

Expert witness Professor Charles Hay, a consultant haematologist at Manchester Royal Infirmary, said Ms Barnes should have been on an increased dose of medication because she was pregnant, and taking body weight into account when deciding the dose she needed was “just a starting point".

He said had she been taking the medication correctly the clot in her lung would not have occurred.

However, the inquest also heard Ms Barnes had not taken all of the doses of medication she was prescribed.

Her partner said he had no reason to believe she would have missed her injections, but said there were three or four days when she did not want him to give them to her.

Recording a narrative conclusion, Coroner Dr James Adeley said Ms Barnes had not been taking the medication correctly, with some doses missed.

He said: “Anti-coagulation did not prevent her death due to non-compliance.

“As to why Laura wasn’t compliant, this is difficult to ascertain, but clearly she hasn’t been taking tinzaparin as it was prescribed.

“If had been in the correct range, Laura would not have died when she did.”

He criticised East Lancashire Hospitals NHS Trust, continuing: “She was not weighed during her admission for this clot, which in my view is a substantial failure and amounted to a guess at the correct dose that should be administered.

“There were further missed opportunities to take tests."

While the hospital's monitoring alone was not the reason for Ms Barnes' death, he said: "This system displayed an almost complete failure at midwifery and obstetric level.

"Even when it did produce a correct result it wasn’t acted on. Any system like this is unfit for purpose."

After the hearing, Ms Barnes mother Jennifer Barnes said she was satisfied with the outcome.

"I’ve got what I wanted, I’ve got the truth. I still feel angry," she said.

“My daughter wanted to be a mum, she wanted to be a mum more than anything and she didn’t get the chance to be a mum.”

East Lancashire Hospitals NHS Trust has been asked to respond to the inquest's findings.

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