A coroner has blasted the East Lancashire Hospitals Trust for using a “hapless” blood monitoring system which was “not fit for purpose” after a morbidly obese pregnant woman died from a blood clot following multiple failings in her care.

Laura Barnes was rushed to Royal Blackburn Hospital on May 29, 2022, suffering a blood clot on her lungs after she failed to take her anti-clotting medication correctly.

She was forced to deliver her son, Dexter Khan-Barnes, by emergency C-section at 32 weeks, but could not be saved and died on the same day, having never met her baby boy.

In a tragic twist of fate, little Dexter died just two months later after being found unresponsive while sleeping in the same bed as his older brother Jackson, and father, Shane Khan.

An inquest into Laura’s death, held in Preston, heard that the 22-year-old, from Rishton, was initially admitted to hospital in January 2022 after experiencing headaches and suffering a stroke while she was around 12 weeks pregnant.

A blood clot was found on her brain at this stage, and she was required to remain in hospital for around a week and given anti-coagulant medication to reduce the size of the clot.

Upon discharge, Laura was given the medication to administer at home, with the dosage being prescribed based on her weight at the time, which had been entered on her records as 151kgs, or 23st 7lbs.

However, at a review three weeks later, on February 14, Laura was re-weighed and found to be 177kgs/27st 8lbs.0

Lancashire Telegraph: Laura BarnesLaura Barnes (Image: Archive)

The inquest was told that it was highly unlikely Laura had gained 26kgs (4st) in that three week time frame and her initial weight at the time of her admission in January must have been recorded in error and taken from notes made in 2018.

Laura had later told her mother, Jennifer Barnes, that she hadn’t been weighed when she was admitted for the stroke in January.

As a result, the dose of medication prescribed to Laura to prevent her from developing further blood clots upon discharge was insufficient.

Despite this discrepancy, Laura’s medication dosage was not increased, and she was asked by obstetrics consultant Dr Sarah Davies to return for further blood tests.

However, only one out of the nine subsequent blood tests – taken in March - was deemed successful with the remainder either failing due to blood samples not being sent to the lab, or because appointments were cancelled.

Dr Davies said she hadn’t been made aware of the failings in the tests until an ante-natal appointment on May 23, six days before Laura’s death.

When senior coroner for Lancashire, Dr James Adeley asked her how she felt about this she replied: “I felt disappointed at this and felt we let Laura down.

“There were significant failings and we failed to act on them…the system is very poor.”

READ MORE: Cause of death for two-month-old baby cannot be determined

Laura collapsed on May 29 due to a massive blood clot on her lung and was taken to hospital but later died following an emergency C-section.

Lancashire Telegraph: Laura's little boy Dexter who died two months after LauraLaura's little boy Dexter who died two months after Laura (Image: Archive)

Professor Charles Hay, a consultant in haematology and professor of thrombosis at Manchester Royal Infirmary, said the initial dosage of medication prescribed to Laura had been based on her weighing 151kgs, but realistically she should have been on a much higher dose due to her weighing 26kgs more.

He told the inquest that had Laura been on an increased dose of anti-coagulant medication she would not have developed the second clot on her lung, which ultimately caused her death.

However, he also said that the dose originally prescribed to her would probably have been sufficient enough to prevent another clot from forming, had she been taking it correctly.

Professor Hay confirmed that Laura was prescribed enough medication to last until April, meaning had she been taking the anti-coagulants twice a day as prescribed, she would have run out a month before her death.

In the days before she collapsed, it was ascertained that Laura had at least a week’s worth of medication remaining, which suggested she had missed several of her doses.

Laura’s partner Shane Khan told the inquest he had administered her morning and evening injections, but when he had to go to work, was told by Laura that she would administer her morning medication herself.

He said he had no reason to believe that Laura would have missed her injections and claimed she had never run out of her medication.

Returning a narrative conclusion Dr Adeley blasted East Lancashire Hospitals Trust for its blood testing system but determined it was not to blame for Laura's death, saying: “The concern is that she was not taking a sufficient amount of anti-coagulation medication.

“As to why Laura was non-compliant, this is difficult to ascertain, but clearly, she had not been taking the anti-coagulant as prescribed.

“Professor Hay said even in the lower range she would not have died when she did.

“The test monitoring system was inadequate, but this is not the reason she died.

“She died because she didn’t take the medication she was prescribed.

“Laura died on May 29 at Royal Blackburn Hospital from a massive pulmonary embolism which she was at increased risk of developing due to previous clots, pregnancy and because she was morbidly obese.

“Anti-coagulant medication did not prevent her death due to non-compliance.”

Since Laura's death, all women requiring blood tests for anti-coagulation levels have had to travel to Manchester.

East Lancashire Hospitals Trust (ELHT) says it has plans to create a team to carry out testing locally, but despite almost two years passing since Laura died, it is not yet fully staffed.

Dr Adeley expressed concerns over the way blood monitoring was carried out by ELHT at the time of Laura’s death, calling it “hapless” and said plans for ELHT to reintroduce a system in-house should not be done until it was fully staffed and fully signed off.

He added: “Neglect by the trust is not appropriate but if the trust attempts to put this system back into operation before it’s fully signed off then I will consider the trust totally fair game.

“This system is hapless, and if the trust is going to do anything in the future it has got to work.”