A young mother died after health workers failed to spot the signs of deep-vein thrombosis less than three weeks after she had given birth by emergency Caesarean.
An inquest heard. Maxine Nour, 24, from Hanwell, collapsed twice in front of the health workers but they sent her home. She died six days later.
A post-mortem found the DVT spread from her pelvis to her lungs in a week.
According to a report in the Evening Standard, paramedics used an ECG to discover she had an abnormally fast heartbeat - a condition known as tachycardia that can be linked to Caesareans - after being called to her home in August 29, 2011, when she collapsed in front of a community midwife.
But when she was taken to Ealing hospital doctors were not told she had undergone an ECG and did not order their own test because Mrs Nour's breathing seemed normal.
Dr Joanna Cook told West London coroner's court: "I didn't request an ECG because I didn't hear of any symptoms. The observations about her were on a paper towel when I first assessed her as the notes hadn't been made up yet. The tachycardia was not on the paper towel."
Later that same day Mrs Nour, who had given birth to a daughter on August 21, collapsed again as she was discharged from the hospital.
She then complained to her husband Zaki of problems breathing and chest pains, and died on September 4, 2011.
Experts said the tachycardia had no bearing on her death, and the inquest also heard she had not complained of pain in her legs, a key DVT symptom.
One expert witness, Luca Fusi, said even if the 'massive embolism' had been spotted on August 29 it might not have saved Mrs Nour. The inquest was adjourned.