The death of a new mother in Northern Ireland could have been avoided had an anaesthetist been consulted, a coroner ruled today.
Mother-of-three Janet Brown, 28, died from morphine poisoning in hospital in 2006.
Belfast Coroner John Leckey said midwives should have sought advice from the duty anaesthetist after the victim started snoring heavily because her airway was blocked.
"An anaesthetic referral may have culminated in a reassessment of her condition and a fatal outcome may have been avoided," he said.
Mrs Brown, from Lisalbanagh Road, Magherafelt, Co Londonderry, was admitted to Antrim Area Hospital on September 12, 2006, following the start of labour during her third pregnancy.
Following a Caesarean section, she was given morphine for pain relief, delivered through a patient-controlled device.
The coroner said that, eight hours after surgery, she was found lying in bed unresponsive and later died.
Mr Leckey added: "On the balance of probabilities, I have accepted that the evidence of Janet Brown snoring heavily is indicative of an evolving upper airway obstruction rather than being merely indicative of her fatigue following childbirth.
"It should have resulted in the midwifery staff seeking advice from the duty anaesthetist, if for no other reason than reassurance, but that did not happen."
The coroner told the packed courtroom the underlying cause of death was morphine intoxication.
He tried to explain the high levels of morphine, but said suggested explanations did not meet the required standard of proof.
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