An inquest has heard that Doctors missed the chance to further investigate high blood pressure in a Liverpool mum who died just hours after giving birth to her fourth child via C-section.
Susan McLoughlin, 33, died shortly after giving birth to her first daughter, Leila, at Royal Hallamshire Hospital in Sheffield in October 2019.
In April 2019, she had undergone a heart test while pregnant at Aintree University Hospital in Liverpool, but the "abnormal results" were not followed up, Sheffield Coroner's Court heard.
A little girl was all Ms McLoughlin and her partner, Jason McKevitt, had "ever wanted", the inquest was told.
The couple, from Netherton, Liverpool, already had three sons together and were excited about the birth of a girl.
Ms McLoughlin died from pulmonary hypertension on 21 October 2019, just hours after giving birth via a C-section at Royal Hallamshire Hospital's Jessop Wing.
She had been diagnosed with the condition a few days before her delivery date, and was transferred to the hospital for specialist treatment.
During the first day of an inquest at Sheffield's Medico Legal Centre the court heard from Professor Suvarna, a consultant cardiothoracic pathologist at the hospital.
Prof Suvarna told the court that, post-mortem, Ms McLoughlin's heart showed clear signs of pulmonary hypertension - a form of high blood pressure that affects the arteries of a person's lungs and the right side of their heart.
Pregnancy was known to interfere dangerously with pulmonary hypertension, as it places additional strain on the body as well as increasing blood pressure.
Prof Suvarna said it was his opinion that Ms McLoughlin's C-section, though normal and conducted without issue, would have put an unmanageable amount of added strain on her already strained heart and lungs.
Prof Suvarna told the inquest that birth via C-section is a "highly stressful few minutes for a woman" and Ms McLoughlin had died due to "not being able to cope with that".
For this reason, he said it was unlikely the condition was present during Ms McLoughlin's previous three pregnancies.
But Ms McLoughlin's family, represented at the inquest by their legal counsel, told the inquest that she had attended A&E in Liverpool years prior in 2015, complaining of chest pain and shortness of breath.
This episode led to an electrocardiogram (ECG) - which measures the hearts rhythm and electrical activity - being carried out, which showed "minor" abnormalities with her heart, the inquest heard.
A second ECG was conducted in April 2019, when Ms McLoughlin was pregnant with Leila, after she had been taken to hospital in an ambulance following a collapse and loss of consciousness when running a short distance for a bus.
Following her second ECG, which also showed abnormalities, Ms McLoughlin was seen by Dr Justin Newstone, a consultant in emergency medicine at Aintree University Hospital.
He said Ms McLoughlin presented as a healthy, young woman and suspected a combination of her being pregnant and not having eaten anything that day had contributed to her momentary loss of consciousness, which had occurred following a short period ofexertion.
Dr Newstone said he "felt at the time that this was a benign problem" as her previous successful pregnancies had "reassured" him there was unlikely to be anything "majorly structurally wrong with [Ms McLoughlin's] heart".
For these reasons, Dr Newstone said he was happy to discharge her on that same day and he did so.
But the inquest also heard from a consultant cardiologist at Aintree University Hospital, Dr Homeyra Douglas, who told the court Ms McLoughlin's "abnormal" ECG results should have resulted in an immediate cardiology referral.
Dr Douglas told the inquest that had Ms McLoughlin been referred to a cardiologist she would have been urgently "pushed through the system" a scan of the heart - likely within 72 hours.
This, Dr Douglas said, may have been able to contribute to an earlier diagnosis of pulmonary hypertension which would have resulted in Ms McLoughlin's pregnancy being closely monitored.
The inquest heard that following Ms McLoughlin's death, Liverpool University Hospitals NHS Foundation Trust conducted an internal review to ensure similar opportunities are not missed in the future.
The inquest was told a Standard Operating Procedure has since been brought in which mandates all ECG tests be reviewed by a senior doctor before a patient is discharged.
The inquest continues.