A woman died while giving birth after a clerical error left her without specialist medical care, despite both her mother and her aunt having been killed by the same rare condition at exactly the same age, an inquest was told yesterday.

Kelly Hutchings, 22, of Fareham, Hampshire, suffered a brain haemorrhage during the birth of her daughter, Nikita, on November 16, 2005. When Ms Hutchings became pregnant for the first time that spring, no appointment was made for her to see a consultant obstetrician despite her family’s “significant medical history” and referrals by her doctor and a midwife. Her need for specialist care was then overlooked by midwives and doctors on up to six further occasions, the inquest in Southampton was told.

Keith Wiseman, the coroner, said that it was “incredible” that a case like hers had slipped through the net, describing it as “like going through six or seven red lights and not realising”.

The inquest was told that Ms Hutchings’s mother, Shirley, had died at the age of 22 while giving birth to Kelly’s brother, Mark, who is now 20. Her aunt, Sue Hickmott, had died in 1982, at the same age and from the same condition, known as deep cerebral venous thrombosis, which causes brain haemorrhage during childbirth.

However, an administrative error by Portsmouth Hospitals NHS Trust meant that an appointment for Ms Hutchings to see Marwan Salloum, a consultant obstetrician, never happened. She was seen finally by a specialist was when she fell seriously ill towards the end of her pregnancy. She was admitted to Southampton General Hospital complaining of dizziness and headaches, but her condition deteriorated and, just over 30 weeks into her pregnancy, she went into labour.

Ms Hutchings, who also suffered from cerebral palsy, was kept alive on a life-support machine while Nikita was delivered by Caesarean section. Her daughter, who has severe disabilities including blindness, cerebral palsy and brain damage, is being raised by her partner, Lee Blyth.

Donna Ockenden, head midwife for Portsmouth Hospitals NHS Trust, explained that Dr Peter Smith, Ms Hutchings’s GP, had first made a referral for an appointment with a consultant. But this was “overridden” and downgraded to a midwife appointment because he had not provided any reason for the request.

A request with details of the family history, was made by June Brown, Ms Hutchings’s midwife. It was approved by Mr Salloum, but Mrs Ockenden said that a “clerical error” meant the appointment was not made because the interview with the midwife was already in place. She added: “Although the history was clearly visible on the front of Kelly’s notes, it was not picked up that it was a high-risk issue.”

Mrs Ockenden said that procedures at the trust had since been changed.

Mr Salloum told the inquest that he considered Ms Hutchings a high-risk case. “The referral that came to my attention had a box that said Kelly was anxious that her mother and her aunt both died in childbirth from a brain haemorrhage. I would like to at least discuss that with the patient.”

Dr Smith said that Ms Hutchings had made no reference to her family history when she came to see him. Her stepmother, Merissa Hutchings, 41, said that she was not a “forceful girl” who would have raised concerns on her own behalf.

The inquest continues.

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