A first-time mother died seven weeks after giving birth after what a coroner said was a “missed opportunity” to assess her condition.
A few days before Gemma Robins, 30, had been due to be give birth, she was admitted to hospital after persistent sickness. She was unable to keep down any food or fluids.
She called the maternity team at University Hospitals Sussex NHS Trust for advice and was told to go to the accident and emergency (A&E) department at Worthing Hospital.
The West Sussex, Brighton and Hove coroner Penelope Schofield said: “Gemma was acutely unwell and a decision was made for her to have an emergency caesarean.
“Gemma remained unwell following the birth and, despite treatment over a period of 40 days on intensive care, she did not recover and sadly died on (Thursday) 13 June 2024.
Just a few days before her daughter was born, Miss Robins had an outpatient appointment where her blood pressure was found to be bordering on high.
The significance of the result did not appear to have been appreciated and, although it should then have been checked a second time, it wasn’t.
Miss Robins was also not pressed to provide a urine sample despite national and local guidelines.
The coroner said that she would issue two PFD (prevention of future deaths) reports and one of these would be about the oversights during the antenatal check up.
It was unclear, the coroner said, what steps had been taken to prevent a recurrence with other expectant women.
Miss Robins gave birth at Worthing Hospital. Shortly afterwards, she and her daughter were transferred to the Royal Sussex County Hospital, in Brighton.
Once there, a consultant said that she was soon found to be “critically ill” even though initially on the surface she seemed well and was “sitting up in bed and talking”.
She turned out to have been suffering from acute fatty liver in pregnancy, a rare condition, and was rapidly developing a severe case of pancreatitis.
Miss Robins, a data analyst who lived in Hove and grew up in Portslade, died from natural causes, according to the coroner, after hearing evidence from about 20 clinicians, many of them consultants.
At Horsham Coroner’s Court, the coroner concluded: “Gemma died from natural causes. However, there was a missed opportunity at her antenatal appointment on (Tuesday) 23 April 2024 to investigate possible pre-eclampsia.
“Blood tests may have revealed abnormal liver function which in turn may have led to an earlier admission to hospital.
Perinatal care found wanting. Hardly unusual these days unfortunately.
Phones are a real problem in hospitals these days as it is so difficult to get through. Switchboard operators know this..as a former telephonist i know it can be difficult. Am very sorry to hear this young Mum died like this.