• Coroner’s inquest into seventh maternal death at Homerton concluded
  • Rules pregnant mother died of “natural causes”
  • Patient’s death highlights areas for improvement in care of pregnant women with heart complications
  • Trust working with neighbour to launch consultant led cardiology-obstetric clinic

A London hospital plans to introduce a new cardiology clinic to its maternity department following the death of a mother and baby, a coroner’s court has heard.

Homerton University Hospital Foundation Trust plans to introduce a cardiology unit to its maternity service, after a pregnant woman died from heart failure earlier this year.

Francesca Victoria Lowe was pronounced dead on 23 January when she was 25 weeks pregnant.

Coroner Edward Buckett ruled this week that Ms Lowe died of “natural causes” related to a congenital mitral valve disease.

Prior to her death, in 2012 Ms Lowe was diagnosed with a congenital heart condition before the birth of her first child. Evidence given at the coroner’s inquest said Ms Lowe was referred for a follow up cardiology appointment three months after the birth of her son in October 2012. She was subsequently removed from the trust’s cardiology register after failing to attend a follow up appointment in January 2013.

The coroner’s verdict said the appointment letter was not copied to her GP. He added he could “not determine with confidence” that Ms Lowe received the letter herself.

In 2016, Ms Lowe was pregnant with her second child and referred for an echo-cardiogram, which was carried out on the 4 January 2017. She died 19 days later.

This is the seventh maternal death at Homerton since 2015. The trust has refused to share anonymised serious incident reports into each death with HSJ.

Despite finding Ms Lowe died of natural causes, the coroner’s verdict said: “None of the consultants at the maternity department hand any real experience in interpreting the results of pregnancy echo-cardiogram [on 4 January].”

He added that “the results of the echo-cardiogram were not communicated to her GP or any other clinician”, but it was noted that there was nothing in the results or symptoms suffered by Mrs Lowe which “would have warranted her urgent referral”.

A trust spokesman said: “The coroner reviewed Ms Lowe’s case and concluded that the death occurred from natural causes.

“However, Ms Lowe’s tragic death did highlight a number of areas where we can improve the safety net around the management of pregnant women who have heart complications.”

Martin Kuper, the trust’s medical director, said: “We have strengthened our processes to ensure closer working between cardiologists and obstetricians and a new system has already been put in place where echo-cardiogram results are communicated to the obstetrics team automatically.

“Working closely with colleagues at Bart’s Health, Homerton is setting up a consultant led cardiology-obstetric unit which is planned to launch in the middle of January.

“Our policies in relation to patients who ‘did not attend’ have been strengthened to make sure that there is a clear process for the management of such patients including handing back of their care to their GPs.”