Doctors missed signs that 'should have raised alarm' over health of mother, 33, who died following childbirth at Sheffield hospital
An inquest in Sheffield opened today (April 29) into the death of a 33-year-old mother from Liverpool who died in the Royal Hallamshire Hospital a short time after giving birth to her fourth child by caesarean section.
Susan McLoughlin died on October 21, 2019, after she suffered a fatal cardiac arrest while still in theatre at Royal Hallamshire Hospital, Sheffield following an elective caesarean at 36 weeks pregnant.
She had been diagnosed with pulmonary hypertension, a rare form of high blood pressure affecting the lungs and heart, just nine days before her death, and transferred from Liverpool into specialist care in Sheffield on October 16.
Assistant coroner Katie Dickinson heard from a pathologist at the inquest that after Susan gave birth, the circulation in her body ‘changed dramatically’.
Her pulmonary hypertension – which is often associated with death during or after labour – meant that her body was unable to cope with these sudden changes and her heart failed.
The inquest heard that prior to Susan’s transfer from Aintree Hospital to the Royal Hallamshire, doctors missed a number of opportunitues to diagnose the pulmonary hypertension.
Susan’s family believe the outcome may have been different had this diagnosis been made earlier.
In September 2015, Susan attended the Emergency Department at Aintree Hospital presenting flu like symptoms and chest pain that worsened with coughing or movement.
A diagnosis of muscular chest wall pain and a lower respiratory tract infection was made.
She had very high blood pressure and an electrocardiogram (ECG) was noted to be abnormal and ‘tachy’(increased heart rate).
Speaking at the inquest, consultant cardiologist Dr Homeyra Douglas said that the abnormal readings from the ECG in 2015 ‘should have rasied alarm’.
In April 2019, while nine weeks pregnant, Susan again attended Aintree Hospital after losing consciousness as she was running with a pram to catch a bus.
Another abnormal ECG result strongly suggested there was a problem with the right side of her heart but, again, a referral for cardiology opinion was not made.
Dr Justin Newstone, consultant in emergency medicine at Aintree Hospital, explained: “If I saw this patient again my actions would be different, but at the time there was nothing in [Susan’s] history that made me think that this could be something quite serious.”
He told the court that the way she presented and had passed out was not particularly unusual for a pregnant woman, especially as she was running and had not eaten that day.
Dr Douglas said: “If the ECG in 2019 had led to a cardiology follow up [Susan] would have been pushed through the system quicker and had an urgent appointment within two weeks.”
Assistant coroner Dickinson summarised: “If she had a cardiac referral [her condition] would have potentially been picked up as pulmonary hypertension and she would’ve been referred to the specialist unit in Sheffield to manager the pulmonary hypertension during her pregnancy.”
Susan also attended an out of hours GP in June 2019 who referred her to have another ECG, however this had to go via her usual GP practice. This was never picked up on.
And at another GP appointment in September 2019 Susan complained of a cough and breathlessness. This was again not considered an indicator for pulmonary hypertension by her GP.
Dr Katie Wilson, of Strand Medical Centre, Bootle, said: “Breathlessness is something you see often during pregnancy. Her presentation was consistent with late stages of pregnancy and of a viral illness [explaining the cough].
"On reflection pulmonary hypertension can present [in that way] and she had a serious underlying condition.”
Susan was eventually diagnosed with pulmonary hypertension in October 2019.
Susan’s sister, Wendy Lunt, who was at the inquest opening, said: “I’ve got fire in my belly and will fight for answers, for justice for the children, and for Susan’s story to be heard.
"If sharing Susan’s story saves someone else’s life then she would have been happy with that.
“It won’t bring their mum back but this will mean we can give the kids the answers in black and white as they begin to ask more questions the older they get.”
She addeed: "It was never magnified just how serious her condition was and if we’d known there was such a high risk of death during the birth Susan would have wanted to leave video message for the kids. But her death was totally unexpected for us all.”
Speaking on behalf of Liverpool University Hospitals, Dr Nikhil Sharma explained to the coroner that a number of imprvements had been made to ensure that a repeat of Susan’s case did not happen in the future.
These include ensuring all ECGs are read by senior doctors, and all doctors are trained to recognise abnormalities and when to rasie them with cardiologists.
Dr Wilson also explained that the system around receiving referrals from out of hours GPs was being reviewed.
Witnesses from Sheffield Teaching Hospitals will be heard at the inquest tomorrow (April 30).
The inquest into the death fo Susan Mcloughlin is due to conclude at Sheffield Medico-Legal centre tomorrow.