HOSPITAL staff have been criticised over the care given to a new mother who died three days after she gave birth by Caesarian section.
Lesley Cowie, 31, suffered a stroke brought on by a haemorrhage of her liver and a liver tumour after she underwent the procedure to give birth to a healthy daughter at Aberdeen Royal Infirmary.
Last year a Fatal Accident Inquiry into Ms Cowie's death heard an allegation from a liver specialist that hospital staff had wrongly treated the expectant mum as if she was a "healthy young woman."
Dr Mervyn Davies said a long-standing problem with lumps on Ms Cowie's liver should have acted as a "red flag" warning over how she should be treated before giving birth in October 2007.
Sheriff Peter Hammond, in his determination yesterday, said her treatment should have been escalated even without the warning.
He criticised the failure to get Ms Cowie seen by a consultant or senior registrar and said there was an "inexplicably long gap" in taking blood samples from her.
However, Sheriff Hammond said there were no reasonable precautions by which her death might have been avoided and there were no defects that contributed to her death in the hospital systems.
The inquiry follows that into the death of social worker Caroline McCall, 38, of Cambuslang, South Lanarkshire, who died just after giving birth by emergency Caesarian in November 2008.
Evidence was heard in both cases that both women had made desperate pleas to medics for help, although the conditions they died of were different.
The Sheriff in Ms McCall's inquiry said she may have lived if she had been seen by a consultant at the Princess Royal Maternity Hospital in Glasgow.
In the latest ruling, Sheriff Hammond said that by September 22, Ms Cowie's temperature had deteriorated and she was unwell.
He added: "She should have been referred to a more senior clinician at that time - a consultant or senior registrar - for review.
"However, the junior staff did not alert the consultant to the unfolding situation with this patient, who had a complex medical history. The seriousness of the situation clearly merited input at a more senior level."
He said since Ms Cowie's death there had been a commendable improvement in the way women are monitored around birth.
NHS Grampian said it would consider the determination before responding.