Doctors missed multiple opportunities to investigate a rare heart condition that killed a young mum hours after she gave birth, a coroner has ruled.
Susan McLoughlin, 33, died at Sheffield 's Jessop Wing on October 21 2019 from pulmonary hypertension, just hours after the birth of her fourth child via a cesarean section.
She and her partner, Jason McKevitt, had three sons when Susan got pregnant with a little girl - Leila - who was all that the couple had "ever wanted".
But Susan tragically did not get the opportunity to know her beloved daughter or continue raising her three sons, Jamie, Jake and Liam.
Susan's condition, which caused high blood pressure in her heart and lungs, had been diagnosed just nine days before her little girl was delivered - but an inquest into Susan's death has ruled that there were "multiple" missed opportunities to investigate and treat the condition sooner.
At the second day of Susan's inquest, held today at Sheffield's Medico Legal Centre, assistant coroner Katy Dickinson ruled that, in total, there had been three previous opportunities for Susan's heart condition to be investigated by cardiologists.
The first, in 2015, was when Susan, from Merseyside, presented at the A&E department of Aintree University Hospital in Liverpool with chest pains and shortness of breath.
An electrocardiogram (ECG) - which measures the hearts rhythm and electrical activity - was performed which showed "minor" abnormalities but this ECG was not looked at by a cardiologist.
Susan had a second ECG in April 2019, while she was 10 weeks pregnant with Leila, after arriving at Aintree A&E in an ambulance, following a loss of consciousness after running a short distance for a bus.
She was again given an ECG which also showed abnormalities but, again, these were not assessed by a cardiologist and Susan was discharged the same day.
The doctor that saw Susan on that day in 2019, Dr Newstone, told the first day of Susan's inquest yesterday that he believed she was a "healthy" 33-year-old woman with a normal pregnancy.
He said that he had attributed Susan's loss of consciousness that day to her having not eaten anything, coupled with a period of exertion while pregnant.
Susan McLoughlin, pictured here with one of her sons, died after giving birth to a little girl (Image: Family handout/Liverpool Echo)
Assistant coroner Dickinson told the court today that this was the second missed opportunity for Susan's heart condition to be investigated, as her ECG should have been looked at by a cardiologist.
However, Mrs Dickinson told the court that it is unclear whether an investigation by a cardiologist would have changed the outcome in Susan's case, though the opportunity for it to be further investigated was clearly missed.
The third missed opportunity to investigate Susan's heart condition was during a second period in 2019, when Susan had attended an out of hours GP service.
The out of hours service had recommended that Susan's own GP practice, the Strand Medical Centre in Bootle, Merseyside, refer her for an ECG in hospital, but this recommendation was not acted upon.
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Five days before the birth of her little girl, Susan's care was transferred from the hospital in Liverpool to the Jessop Wing in Sheffield, so that pre-delivery care could be given to Susan in light of her pulmonary hypertension diagnosis, made four days earlier.
Giving evidence at her inquest today was Dr Condliffe, a consultant physician at the Pulmonary Hypertension Unit of Sheffield Teaching Hospitals.
He told the court that, had Susan been referred to care in Sheffield sooner, she would have been advised to terminate her pregnancy - as pregnancy is well-known to dangerously interfere with pulmonary hypertension, increasing the likelihood of a patient's death.
Consultant cardio-thoracic pathologist at the Royal Hallamshire Hospital, Professor Suvarna, told the first day of Susan's inquest yesterday that it is likely Susan's c-section put an unmanageable amount of strain on her already strained heart and lungs.
He said that birth via a c-section is a "highly stressful few minutes for a woman" and Susan would likely have died due to "not being able to cope with that, she was not able to reset her circulation".
Today, Dr Condliffe said that there had been "no unexpected issues" during Susan's c-section delivery, but that her blood pressure dropped dangerously low after her birth and she went into a cardiac arrest, with doctors attempting to resuscitate her for "around an hour and a half" before it was decided that her life could not be saved.
When asked if Susan would have survived had she been referred for care in Sheffield during the period where she lost consciousness, in April 2019, Dr Condliffe said that it is "difficult to be 100 percent sure".
But, he told the court: "It's a reasonable assumption that the risk of dying would be lower."
Concluding Susan's inquest, Mrs Dickinson recorded a narrative verdict and told the court that the facts of the case were that she died on October 21 2019 at the Jessop Wing, following a c-section.
She told the court that the two occasions where Susan's ECG's were not looked at by a cardiologist and the one occasion where her GP failed to refer her for a third, were "missed opportunities to carry out further investigation by a cardiologist".
Mrs Dickinson passed on her condolences to Susan's sister, Wendy Lunt and her partner, who were both in court today and she told them: "She [Susan] sounded like a lovely woman, I'm so sorry."