There were failures in the care of a Blackburn woman who took her own life after her mental health deteriorated having suffered from an extreme form of pregnancy sickness.

This was the conclusion of a two-day inquest into the deaths of Jessica Cronshaw and her unborn daughter Elsie, which took place at Accrington Town Hall.

Jessica was 28 weeks pregnant with her daughter Elsie when they both died in November 2022, as Jessica battled a condition called hyperemesis gravidarum (HG).

The 26-year-old had suffered from the severe pregnancy sickness since finding out she was pregnant with Elsie.

The inquest heard evidence from leaders of the organisations who were involved in Jessica’s care.

Coroner Kate Bissett said she was satisfied the level of care Jessica received during her time at Royal Blackburn Hospital and from GPs contributed to the deterioration of her mental health, and this deterioration was the “primary cause of her actions.”

On day two of the inquest, the court heard from Carmel Hindle, patient safety investigator and a registered midwife and nurse.

She said Jessica was not weighed routinely throughout her pregnancy and enquiries did not take place to assess her compliance with the medication she had been given.

Ms Hindle added Jessica’s mental health and wellbeing were not assessed in line with guidance, and Jessica had returned responses that were, in hindsight, red flags, but midwives were unaware of what constituted a red flag.

Martin Maher, from East Lancashire Hospitals Trust, said mental health screenings were not being performed with every routine contact as they would expect, but there had now been updated local guidance to a whole pregnancy approach.

Jessica and Elsie feature as part of new training, though not by name and on an anonymised basis, and there will be a pregnancy sickness support webinar for ELHT staff in gynaecology and maternity services held next month.

Philip Holden, representing the family, said Jessica was “happy and without mental health symptoms” before contracting the condition, and HG had a “massive affect on her mental health and led to her deterioration”.

Jessica and her partner, Edward, found out they were expecting a baby in June 2022. Within a short time of falling pregnant, Jessica began to struggle with sickness.

She was prescribed with anti-sickness medication but continued to struggle significantly, and was unable to continue working as a primary school teacher.

She had several telephone consultations with GPs before being diagnosed with HG in late June.

Jessica was prescribed with further anti-sickness medication but was told to wean herself off them slowly, without any medical assistance on how to do that.

Throughout her consultations and appointments, there was no recorded documentation regarding whether midwives and nurses had checked on Jessica’s mental health.

Jessica had never disclosed any thoughts of suicide or harm, though one midwife admitted she should have pushed the subject more.

On November 14, 2022, Jessica and her mum had been to Dunelm in Blackburn to buy things for Elsie.

She was seen at around 6.40pm that evening by her stepfather, but by 7pm she was found unresponsive.

Her family began CPR and paramedics arrived. Though her heart was restarted, she suffered another cardiac arrest.

Elsie was delivered but died four days after her birth on November 18. She was placed into her mother’s arms.

Jessica died the following day, with Ms Bissett giving a cause of death of hypoxic brain injury caused by hanging.

Ms Bissett said: “It’s very clear to me if love alone could have saved them, then we would not be sitting here today.

"Jessica was and is a much loved daughter, granddaughter, sister, partner, and school teacher. And a mother, who loved her baby daughter.

“Elsie’s life was tragically short but nonetheless filled with love and meaning. I’m so very sorry for the loss of these two beautiful girls.

“I am satisfied the impact of Jessica’s care contributed to a deterioration in her mental health. I accept a major factor was HG itself but the care contributed.”

Ms Bissett offered a narrative conclusion, in which she said Jessica died as a result of injuries caused by a lack of oxygen to her brain.

Elsie was delivered and cared for but damage caused by a lack of oxygen was not survivable.

She added: “Their deaths are utter tragedies.

"There needs to be further awareness about the crippling impact of this condition and how it can impact the lives of those who suffer from it.”