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A new mum who was dying from a blood clot was told to ‘go home and have some fun’ by a GP who advised her patient she was having an anxiety attack,’ an inquest heard.
Michelle Roach, 32, died of a blood clot on her lung in 2014, just over a month after giving birth to her daughter, Mackenzie-Lee.
Her grieving husband told an inquest how much she had been looking forward to being a mother.
But after she collapsed, Dr Nuala Morton advised she was having a panic or anxiety attack and told her to ‘come back when she’d relaxed a bit,’ an inquest was told.
Two days later, the mum tragically died.
At the conclusion of a four day inquest today Senior Coroner Heidi Connor ruled that the new mum died from natural causes.
But she singled out Dr Morton saying the death was contributed to by neglect in her clinical treatment before being admitted to hospital.
The inquest had heard that she failed to diagnose her patient’s pulmonary embolism despite her showing all the warning signs.
Even after the mother-of-one had collapsed for the second time Dr Morton had told her she was having an anxiety attack.
When Michelle’s husband called the GP the next day and told her Michelle was too weak to even get out of bed, the GP said she could wait for four more days before needing to be seen.
The Senior Coroner for Berkshire Ms Connor said in delivering her verdict: "It is likely that she (Michelle) was short of breath, or at the very least, reported suffering this symptom earlier that day.
"She was not referred to hospital to investigate the possibility of pulmonary embolism.
"Dr Morton spoke to Michelle’s husband on the telephone the next day and was told that Michelle had deteriorated.
"She advised that Michelle could wait four days to be seen again."
Her husband George Roach said today after hearing the verdict: "I was incredibly angry with the NHS when Michelle lost her life and I lost all trust in medical professionals.
"It made me second guess everything they said, which makes raising a six-week-old baby by yourself, whilst grieving for your wife, even harder.
"We put our full trust in the NHS and I feel as if some of the staff went for the easiest diagnosis when presented with her symptoms.
"Although I believe that individuals should face consequences for their actions, but also be forgiven, I also believe that this is an example of the systemic failings of the NHS."
George told the inquest how Michelle had collapsed for the first time on January 15 when they took baby Mackenzie-Lee for her first walk.
After only a few minutes she had turned to him and said she could not breathe and collapsed.
They had visited Dr Morton and the inquest heard she had failed to ask whether Michelle had been unconscious and failed to make some basic checks for pulmonary embolism.
January 29 was the day of Michelle’s six week check-up after giving birth and she collapsed again.
George, in evidence to the inquest in Reading, Berkshire, said: "She looked at me and her eyes rolled back and she collapsed and started making what can only be described as weird noises.
"Dr Morton advised that Michelle was having a panic or anxiety attack and said ‘go away and do something fun and then come back when she’s relaxed a bit’."
The inquest heard that Dr Morton had noted that Michelle was "anxious plus plus, and panicky", but had not noted down Michelle’s blood pressure, that she had fallen unconscious or that she was short of breath.
Dr Morton claimed that Michelle had not been short of breath at that consultation.
The next day, January 30, Michelle’s condition worsened and George called Dr Morton at 8.50am but it wasn’t until gone 6pm in the evening that Dr Morton made a home visit.
It was revealed that when the GP visited Michelle on the day before her death she was too weak to get out of bed.
The GP called the emergency services and asked for a one to two hour ambulance attendance instead of a blue light emergency call.
Finally Michelle was rushed to the Royal Berkshire Hospital where she waited in a corridor for two hours.
She was then seen by a junior doctor who had limited experience with PE patients and failed to diagnose her.
Michelle was not given an IV drip or clot busting drugs.
The coroner said: "Anticoagulants were not given. Early Warning Score charts were not fully completed.
"She was not reviewed by a senior doctor."
Michelle had a cardiac arrest at shortly before 1am on the next day, January 31, where she cried out in pain and said she could not breathe.
A cardiac team assembled to try to save her but she had another arrest at just over half an hour later and quickly deteriorated until she died at 2.22am on January 31 of pulmonary embolism.
The coroner concluded she died of "natural causes contributed to by neglect in her clinical management" during the time she under the care of Dr Morton.
Following the verdict, George said through his solicitors Slater Gordon: "Waiting nearly five years to discover what happened to my wife has had such a huge impact on our lives and the grieving process.
"You try to take steps to move forward with your life, a process that is so important for me, to make sure I am the best dad I can be for my little girl, but it feels as if you take one step forward and then twenty steps back.
"It carries this real sense of fear that you will be propelled back into the initial stages of grief and be forced to relive the whole thing again.
"I was incredibly angry with the NHS when Michelle lost her life and I lost all trust in medical professionals."
He added: "We put our full trust in the NHS and I feel as if some of the staff went for the easiest diagnosis when presented with her symptoms.
"Although I believe that individuals should face consequences for their actions, but also be forgiven, I also believe that this is an example of the systemic failings of the NHS.
"Michelle was my better half in a number of ways and such a wonderful person.
"She was so excited to be a mum, especially as we struggled to fall pregnant for a number of years and had reached the point of thinking it might never happen for us.
"When we found out we were pregnant, it was phenomenal news and the only thing Michelle spoke about for the first six weeks.
"Kenzie knows who her mum is, I have made sure of that. She has a large picture of the three of us, when she was first born, up in her room, and I have told her that her creative gene definitely comes from Michelle who was always drawing and painting.
"I really hope that some lessons can be learnt from this and the right people take note, so no other families have to face a similar and avoidable tragedy."
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