A mum-of-four who died soon after giving birth would have been advised to have an abortion if her deadly condition had been spotted in time, an inquest heard.
Susan McLoughlin, 33, suffered a cardiac arrest shortly after undergoing a caesarean section to deliver baby girl Leila on October 21, 2019.
Her devastated partner Jason McKevitt was left to raise their four children alone.
A few days before going into labour the mum, from Netherton, Liverpool, had been found to be suffering from pulmonary hypertension, a dangerous and rare form of high blood pressure affecting the lungs and heart.
After being diagnosed at Aintree Hospital, Susan was referred to a specialist unit at Sheffield's Royal Hallamshire Hospital, reports the Liverpool Echo.
Assistant coroner Katie Dickinson concluded there were three missed opportunities to investigate Susan's troubling symptoms which began months earlier.
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Recording a narrative conclusion at Sheffield Coroner's Court, she said Susan should have been referred to cardiology teams months before on April 17, 2019, after being rushed to Aintree A&E when she fainted while running for a bus.
On Thursday, Dr Justin Newstone, a consultant in emergency medicine, accepted Susan had been discharged despite an abnormal ECG result which experts said suggested damage to the right side of her heart.
He told the court the fact she seemed well, had undergone three successful pregnancies in the past, and was young meant he did not suspect a major underlying heart condition.
Ms Dickinson also found that Susan's GP practice, The Strand Medical Centre in Bootle, failed to act on a letter from the out-of-hours 'GP Extra' service asking for another ECG scan to take place after a consultation on June 20, where Susan had complained of breathlessness.
The court found Susan should also have been referred to cardiology teams September 21, 2015, when she attended Aintree with chest pains and other symptoms and ECG results were abnormal.
Although doctors told the inquest it was unlikely her pulmonary hypertension would have been evident that long ago.
Today, Dr Robin Condliffe, a consultant specialising in respiratory medicine at the Royal Hallamshire Hospital and an expert in pulmonary hypertension, was asked what his advice would have been if she was diagnosed around two weeks after her attendance at A&E in April 2019.
He said the "standard recommendation is termination", due to the mortality risk of 20 percent - but that if the mum was against this, other treatments could have started earlier.
Susan did not get diagnosed with the dangerous condition until she began coughing up blood towards the end of her pregnancy.
And so the specialist unit in Sheffield were only able to begin treating the condition around a week before birth.
Giving her narrative conclusion this afternoon, Ms Dickinson said both abnormal ECG findings from September 2015 and April 2019, should have been referred to cardiology for investigation.
She also noted the GP Extra advice in June 2019 not being acted on.
"All of the above findings were missed opportunities to carry out further investigations by cardiologists," she said.
"It is not clear whether those missed opportunities would have changed the outcome," the coroner added.
Mrs Dickinson told the court she was satisfied with changes made by both the hospital trust and GP surgery to make sure similar mistakes are not repeated.
Yesterday Susan's GP, Dr Katie Wilson, told the court the way referrals are handled by admin staff has changed, and the court was told today two members of staff must sign off each email or letter.
Following the hearing, Susan's sister Wendy Lunt, 41, who was with her when she died, said: "She was just a loving mother; everything was about her kids.
"Her death has left an absolute gap in the household."
