A Sheriff has criticised the sub standard care given to mother-to-be Caroline McCall before her death at one of Scotland's leading maternity units.
Ms McCall, a 38-year-old social worker from Cambuslang in South Lanarkshire, was given the heartburn remedy Gaviscon when she was admitted to Princess Royal Maternity Hospital in Glasgow with what she believed to be a heart attack.
She died clutching her chest in pain almost two days later of severe heart trauma, having never been seen by a consultant obstetrician. Her premature baby was safely delivered by Caesarian Section almost 20 minutes after she finally collapsed.
Following a Fatal Accident Inquiry at Glasgow Sheriff Court last summer, Sheriff Daniel Scullion has now ruled her death might have been avoided if she had been seen by a consultant in obstetrics.
He said there were four opportunities to carry this out, when she was first admitted to the Princess Royal Maternity Hospital on the morning of November 24 2008; during the morning ward round or later that day; or when she was rushed to the hospital's high dependency unit on November 25.
She may have lived if she had been seen by a senior physician or if heart problems had been considered.
Sheriff Scullion also highlighted a defect in the hospital's systems, which did not ensure an outstanding request for a review of an obstetric patient was highlighted as part of shift handover.
He said: "Caroline was admitted to a major maternity hospital because she was unwell.
"She died some 41 hours later, without a consultant obstetrician having seen her and without a consultant having been involved in any aspect of her treatment before the fatal collapse that immediately preceded her death.
"Indeed, no evidence was led to suggest that prior to that collapse at 6.30am on November 26 2008, any consultant was aware that she was an inpatient.
"The lack of consultant obstetrician involvement clearly amounted to substandard care."
The rare condition which killed Ms McCall, Aortic Dissection, a rupturing of the heart, went undetected by medics and was only discovered during the post mortem examination. Cases of Aortic Dissection have actually increased in expectant mothers in the five years since Ms McCall's death.
Sheriff Scullion added: "Something needs to be done to improve the rate of detection of Aortic Dissection in expectant mothers.
"If it has not already done so, Greater Glasgow and Clyde Health Board should initiate discussion with the appropriate medical authorities, designed to ensure that the issue of improving the detection in expectant mothers of the life-threatening condition receives appropriate attention."
The FAI report was welcomed by Alan Muir, 46, Ms McCall's partner and father of her five-year-old daughter, Grace.
He said: "The family's position has always been that Caroline was not given a chance.
"That view has been borne out in the Sheriff's report."
Mr Muir is suing the health board and said the family now want it to accept responsibility for her death and dispense with the need for more upsetting days of evidence in court.
A spokesman for the health board said: "NHS Greater Glasgow and Clyde would like to reiterate its deepest condolences to this patient's family for their loss.
"We have only just received the Sheriff's determination. We will examine the determination in detail including any recommendations."