Coroner's anger as woman, 22, dies giving birth - at same age and in same way as her mother and aunt

But a hospital's administrative blunder meant she was not seen by a consultant until she fell ill. And then it was too late, an inquest heard on Tuesday.

Miss Hutchings, like mother and aunt, died from a brain haemorrhage and at the inquest the coroner said he found it incredible her family background had "slipped through the net".

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Happy times: Kelly Hutchings with her partner Lee Blyth

Keith Wiseman said the oversight at Southampton General Hospital was "like going through six or seven red lights and not realising".

Miss Hutchings, from Fareham, Hampshire, died at the hospital on November 16, 2005, before she was able to see her baby, Nikita, who weighted just 3lb 6oz.

The child was delivered by Caesarean section while Miss Hutchings was kept alive on a life-support machine.

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Nikita has severe disabilites including cerebral palsy and is being cared for by Miss Hutchings's partner, Lee Blyth.

The inquest was told that due to an administrative error by Portsmouth Hospital NHS Trust Miss Hutchings was not seen by specialists about her family history until she fell ill.

She had visited her GP when she was eight weeks pregnant but did not mention her family history of death in childbirth.

Consultant obstetrician gynaecologist Marwan Salloum said he later received referral papers from a midwife highlighting Kelly's problems and noted her as a high-risk case.

He ticked a box asking for her to be seen by a consultant but due to the administrative error, she was never booked in for an appointment.

"Where there is a strong family history of death in childbirth, one would want to look into the possible causes of that," he said.

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Kelly's aunt: Sue Hickmott also died at 22

"It may not have made any difference in this case, but it would have let us look at the possibilities."

Head of midwifery at Portsmouth Hospitals NHS Trust, Donna Ockenden, said that for some unexplained reason the appointment with the consultant was never booked in.

A new system has now been set up.

Outside the hearing, Kelly's stepmother Merrisa Hutchings, 41, said her death had "destroyed" her father Les, 42.

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In 1982, his sister-in-law Sue Hickmott died during childbirth. Her child later died.

In 1987, his then wife Shirley died when she was six months pregnant with Kelly's brother Mark, who is now 20.

The inquest continues.