A new mother who suffered bleeding on the brain and died - just weeks after giving birth to her son - was the victim of "gross failures" by the NHS trust caring for her, an inquest has heard.
During her labour at Croydon University Hospital in October 2010 Malgorzata Doniec was given an epidural by a trainee anaesthetist.
But this was unsuccessful and the needle used to administer the anaesthetic punctured the dural membrane at the base of the spine, causing cerebrospinal fluid to leak into the epidural space.
This problem, known as a dural tap, caused her to suffer agonisingly painful headaches as fluid built up in her skull.
But note-keeping errors meant the causes of her symptoms were missed by GPs and midwives in the weeks after the birth.
And further problems meant when she was admitted to hospital in the days before her death there were failings in her care, the inquest at Croydon Coroner’s Court was told.
Coroner Dr Roy Palmer described the errors as "a missed chance" to save Miss Doniec's life.
But Sarah Simcock, representing Croydon Health Services NHS Trust said the evidence presented at the inquest had not beem sufficient to show neglect by the trust.
Miss Doniec, of Essex Grove, Upper Norwood, died on November 3, 2010, just under a month after giving birth.
The inquest heard on Monday the fact she had suffered a dural tap while in labour was recorded on her medical notes but was not highlighted on the summary sheets.
This meant it was not known about by most of the medical staff caring for her.
Expert witness Professor Trevor Beedham told the court: "It is a major oversight there is nothing in the main discharge summary so neither the GP nor the A&E department could know.
"That is an area of substantial criticism."
Counsel for the Croydon Health Services NHS Trust, Sarah Simcock, admitted this was an error, saying: "The trust accepts the dural tap should have been recorded on the discharge summary at the time.
"I cannot explain why it did not go on this one.
"We expected it to then and we expect it to now."
And she told the court since Miss Doniec’s death the trust has also come up with a red sticker system to flag up the issue on patient’s notes.
Professor Beedham told the inquest he also felt the community midwives should have asked a neurologist for advice when the patient’s headaches did not go away after a few days.
And Prof Beedham says there were further problems with Miss Doniec’s care after she was admitted to Croydon University Hospital by ambulance just after midnight on October 30.
The 43-year-old was given a painkillers injection but it was then around three hours later before she was seen by Dr Maja Gavrilovski.
Giving evidence to the inquest she said she was aware there had been epidurals but not aware of an epidural tap.
Dr Gavrilovski suspected Miss Doniec’s problems arose from inter-cranial pressure but was unable to order a CT scan in the A&E because out of hours these were only for patients with head injuries.
Miss Doniec was not admitted to the care of medical ward staff until around 6am and not seen until around noon, with no-one phoning the neurology specialists at St George’s Hospital to ask for advice.
Prof Beedham said: "The consultants do not seem to have been very involved at any stage as far as I can see and there is nothing of escalating it to get their opinion.
"I would argue the failings after the 30th of October constituted a gross failure to provide comprehensive medical attention."
But Miss Simcock, representing the Trust, addressed coroner Dr Roy Palmer and said: "The evidence you have is not sufficient for neglect."
The inquest, due to finish next week, continues.
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