A 33-YEAR-old expectant mother with a history of deep vein thrombosis (DVT) died of natural causes due to neglect, a coroner concluded.

Vicky Bennett, 33, of Ebbw Vale - around seven weeks pregnant when she died in July 2017 - complained of breathlessness and fatigue to several medical professionals, but no link was made to her condition.

And one of those involved in Miss Bennett's care conceded at an inquest hearing that not enough was done to help her.

Miss Bennett suffered DVT in 2014, putting her at high risk of a blood clot forming in the deep veins in her legs or arms, once pregnant.

She died on July 2 2017 at Bristol Royal Infirmary (BRI), after being airlifted there following a cardiac arrest. She subsequently suffered a serious brain injury.

In a statement read at the hearing at Newport's Coroners Court, BRI consultant Chris Bourdeaux, said a "massive" pulmonary embolism - a blood clot which travels to the lungs from deep veins in the legs - was found.

Her father Paul Bennett, in a statement, said his daughter told a midwife on June 14 2017 that she had been short of breath.

Her partner, Stuart Jenkins, said: “She would be getting short of breath just sitting down. It was all the time.”

“She was complaining of a pain in her leg and thighs, and on June 25 I noticed swelling.”

Tracey Holmes, then an advanced nurse practitioner at Abergavenny's Nevill Hall Hospital, assessed Miss Bennett on May 22 2017, and said her blood pressure, temperature and respiration were normal. She arranged an ultrasound scan for two days later, to determine if the pregnancy was viable.


“Vicky said in a verbal assessment she had suffered DVT,” said Ms Holmes.

“This information is in a set of notes which are then made available to the doctor (performing the scan).”

Gynaecologist Subrata Majumdar said he was unsure whether the notes were in the room before he conducted the scan.

Senior coroner for Gwent, Caroline Saunders, asked him: “Either those notes were not there or they were available to you and you didn’t notice.

He replied “that’s possible" - and said that had he been aware of her DVT history, he would have prescribed anticoagulation medicine or referred her to a haematologist.

Giles Colin, representing Miss Bennett's GP Dr Paul Treasure, asked whether, if thrombo-prophylaxis treatment had been taken around May 24 to prevent a clot forming in her legs, Miss Bennett’s death might have been prevented.

Mr Majumdar said studies have shown an 88 per cent success rate.

Claire Haymond, a community midwife at Ebbw Vale Hospital, said she saw Miss Bennett once, on June 14 2017.

She conceded that even though complications as a result of DVT are common for expectant mothers with the condition, especially early in pregnancy, not enough was done to help Miss Bennett.

She could not recall informing her of the increased risks, and the information was not shared with her doctor.

“At the time there was no clear pathway to relay the notes to Vicky’s GP,” she said, but accepted that the information was too important to ignore, and should have been shared with the GP.

Special stockings usually made available to expectant mothers with DVT, were not made available to Miss Bennett because the hospital did not ordinarily offer them to patients.

Dr Treasure said he has thought about his approach to Miss Bennett on “multiple occasions” and apologised to her family for being unable to save her life.

During an appointment on June 19 2017, he suggested Miss Bennett's breathlessness might be due to warm weather.

He recalled ruling out a pulmonary embolism, choosing not to refer her for diagnostic tests, and instead organising blood tests.

Dr Treasure said Miss Bennett did not inform him of her DVT, and had he known of it, he would have acted differently.

Aneurin Bevan University Health Board's investigating officer, Paquita Sanges, said lessons were learned from Miss Bennett’s death.

There was no evidence Miss Bennett was told she was at high risk during pregnancy due to her condition, and Ms Sanges said “a general lack of awareness about DVT” among healthcare professionals affected her treatment.

“Safety alerts have been circulated around all of our primary care units to inform healthcare workers about the impact DVT can have on expectant mothers,”she said.

“Midwives will now refer patients to specialists at the earliest opportunity once they are made aware of a DVT diagnosis.”

In 2018, an event in aid of the charity Thrombosis UK was held in memory of Miss Bennett, and her family and friends paid fulsome tribute to her.