A pregnant woman from Ebbw Vale died after medical staff failed to treat a serious health threat, an inquest has heard.
On Wednesday, Gwent Coroner's Court heard how 33-year-old Vicky Bennett was repeatedly told she was not at high risk of suffering a blood clot.
She was airlifted to hospital in Bristol after vomiting and collapsing at home in 2017, but her condition deteriorated and she later died.
Miss Bennett suffered a deep vein thrombosis - a blood clot that develops within a deep vein in the body - in 2014.
Those who suffer a blood clot are at a greater risk of suffering a pulmonary embolism in the first and third trimester of pregnancy.
But the mum-to-be was not told about symptoms to look out for or prescribed medication to reduce the chance of it recurring.
In May 2017, Miss Bennett attended the emergency department at Nevill Hall Hospital within the first weeks of her pregnancy after suffering bleeding and abdominal pain.
Junior clinician fellow Ioannis Mitsakis said he saw Miss Bennett at the early pregnancy assessment unit.
He said he did not refer her to specialists for preventative treatment as a scan had not yet determined if the pregnancy was "viable".
Two days later, Miss Bennett attended the pregnancy unit for an ultrasound scan and was told her pregnancy was not possible.
On both occasions she was seen by consultant obstetrician and gynecologist Dr Subrata Majumdar.
Attending Wednesday's hearing, Dr Majumdar said he was not aware of Miss Bennett's previous blood clot and could not recall whether her medical notes were in the room at the time of the scan.
The consultant said he would have referred Miss Bennett to the haematology department for preventative medication if he had known.
He said: "It's possible the notes were not available and I proceeded with the scan without having the notes."
In June, Miss Bennett attended her first appointment with community midwife Claire Harmond. Miss Harmond said Miss Bennett's previous blood clot was discussed as part of routine checks but no further action was taken.
The midwife added Miss Bennett had not mentioned suffering from shortness of breath, a potential symptom of deep vein thrombosis.
When asked if she had alerted Miss Bennett's GP or the hospital of her medical history, Miss Harmond said: "At that time there was no pathway to refer Vicky...the practice was at 12 weeks when you go for a first scan that's where the decision was taken."
Miss Bennett Glanrhyd Surgery in Ebbw Vale later that month raising concerns over low energy levels and shortness of breath.
Dr Paul Treasure said Miss Bennett did not tell him of her previous deep vein thrombosis so he did not check her legs for swelling - a symptom of a clot.
He said Miss Bennett had suggested her shortness of breath could have been caused by the hot weather at the time of the appointment.
He said: "I had no reason to expect a pulmonary embolism, it was not something Vicky herself was concerned about."
Miss Bennett collapsed in her home on June 29 after suffering what was described as a "massive" pulmonary embolism.
She was airlifted to University Hospitals Bristol but her condition deteriorated and the decision was taken by her family to remove life support on July 2.
Governance midwife for Aneurin Bevan Health Board Paquita Sanges said an internal investigation had been carried out since Miss Bennett's death.
Policy has since changed in the health board to raise greater awareness of pregnant women suffering from blood clots.
Asked why health care professionals had not "appreciated" the risks posed by DVT in the first trimester of pregnancy, Ms Sanges said it was knowledge the doctors knew in "theory" but not in "practice".
Miss Bennett's medical cause of death was given by hypoxic brain injury caused by cardiac arrest as a result of bilateral pulmonary embolism.
Coroner Caroline Saunders gave a conclusion of death caused by natural causes contributed by neglect.