Baby dies weeks after tragic mum who he never met

AN inquest heard a pregnant mum, who died from a severe blood clot after a series of tests was "let down."

Laura Barnes was heavily pregnant with her son Dexter when she collapsed in May 2022. The 22-year-old gave birth via emergency caesarean section but never regained consciousness.

In a double tragedy for the family, Dexter died two months after his mum, who never got to meet her son.

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An inquest into the 22 year old's death on April 30 revealed she was 15 weeks pregnant with Dexter when she first attended Royal Blackburn Hospital in January 2022. She was diagnosed with a clot in a vessel within her skull and was put on tinzaparin, an anti-coagulant used to treat deep venous thrombosis and prevent blood clots from forming.

However, Preston Coroner's Court hearing heard she wasn't given the correct dose of medication and there is no evidence Laura was ever weighed to determine the correct dose, reports Lancs Live.

The hearing was told Laura's weight was recorded as increasing from 151kg to 177kg in just three weeks. Several doctors stated this level of weight gain was highly unlikely and it was probable her weight had been taken from her records four years earlier.

Laura, who was also mum to her son Jackson, confided in her own mum, Jennifer, that she hadn't been weighed during her hospital stay for a stroke in January. This oversight meant the medication prescribed was too low to prevent another blood clot from forming.

Given her high-risk pregnancy status due to her weight and a previous bout of pre-eclampsia when she was carrying Jackson in 2018, Laura was under consultant care. When Dr Sarah Davies, an obstetrics consultant, noticed Laura's anti-coagulation levels were dangerously low, she ordered regular blood tests.

Out of nine scheduled blood tests, only one was completed successfully. The rest were botched samples that either weren't sent to the lab or appointments which were cancelled.

Dr Davies said that when she realised in May 2022 that the sole successful test from March showed Laura was "chronically under-anticoagulated" she didn't adjust the dosage. Just six days later, Laura, who weighed 189kg (29 stone), died from a blood clot in her lung.

Dr Davies acknowledged multiple "significant failings" in Laura's treatment, expressing the mistakes were both "disappointing" and "frustrating". Senior Coroner Dr James Adeley then questioned Dr Davies on her feelings upon learning the tests had not been carried out.

She said: "Disappointing... I feel that we let Laura down. It is a very poor system."

On May 23, the last time Dr Davies saw Laura, she requested an urgent blood test. She said: "I found out afterwards that Laura had fainted during one of the blood tests; the message about the importance of it going to the lab wasn't relayed.

Dr Adeley asked: "Another failure? " to which Dr Davies replied: "Yes."

After Laura collapsed on May 29, 2022, Dexter was delivered via emergency caesarean section. Two months after Laura's death, Dexter 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 heart-breaking that Laura had never been able to meet 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.

Prof Hay said: "Not enough heparin had been dispensed to cover the whole period and we know from the GP's evidence that the practice didn't prescribe; neither would I have expected them to. Either doses were missed or she ran out a month or so before she died."

Laura's former partner, Shane, claimed he would leave for work in the mornings while Laura was still asleep. He said she had promised to administer her morning injections herself, a claim disputed by Laura's mother. Shane also insisted he had no reason to suspect Laura hadn't been taking her injections and maintained she hadn't run out.

Moreover, at her final antenatal appointment on May 23, just before her death, Laura stated she still had a week's supply of injections left. The coroner told Shane: "It would appear that Laura is not having her doses of heparin twice a day; she can't have been or you would have run out."

Since Laura's death, all women needing blood tests to determine anti-coagulation levels have had to travel to Manchester. East Lancashire Hospitals NHS Foundation Trust (ELHT) has plans to establish a local team, but it is yet to be fully staffed, despite nearly two years passing since Laura's death.

Dr Adeley expressed serious concerns about ELHT's consideration of reintroducing an in-house system for anti-coagulation level testing. He stated: "The way in which the monitoring was carried out in this case... it is not even vaguely fit for purpose. 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."

Speaking on the case, Dr Adeley who gave a narrative conclusion expressed: "The fact that the treating consultant was unaware that eight out of nine tests failed shows that this system was a complete failure."

"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."

He also voiced his misgivings about what he termed a "hapless and lackadaisical" system. However, he stated Laura's cause of death was her failure to take tinzaparin correctly.

Dr Adeley said: "Even at the lower doses it would have prevented a clot forming.

"Laura Jane Barnes died on May 29, 2022, at the Royal Blackburn Hospital of a massive pulmonary embolism. A risk was significant due to previous clots, pregnancy and morbid obesity. Anti-coagulation did not prevent her death due to non-compliance."

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