THE review into the maternity unit at Northwick Park was sparked following the deaths of three women in ten months.

Woman A

The first woman died on June 5, 2007, from a blood clot on her lung.

She had missed several doctors appointments before delivery, despite going to hospital with abdominal pain at 34 weeks.

She gave birth to a healthy baby four days later than expected, but three weeks later, she died in an ambulance, on the way to Northwick Park, having been discharged some time earlier.

The 25-year-old mother of two was considered “high risk” because of her weight; she had a body mass index of 40, when 18.5 to 25 is considered normal.

As a result she had been referred to a health visitor after leaving Northwick Park, though it is unclear what care she was given.

Woman B

The second woman to die at the unit in the ten-month span died of a massive haemorrhage, on September 18 She had been to the hospital several times with vaginal bleeding.

The 39-year-old’s cause of death was recorded as an Amniotic Fluid Embolism (AFE).

The condition is caused when liquid from the uterus enters the blood stream of the mother, leading to an allergic reaction.

Ann Groves said it was a rare complication which cannot be predicted or prevented.

However, Ms Groves said in her report that the mother should have been identified as a “high risk” patient by staff at the hospital after the early haemorrhages.

This would have meant she would have been monitored more closely.

The first-time mother had been given scans in an effort to identify the cause of the problem but the results of the scans did not reveal anything out of the ordinary.

Woman C

The third death was that of Zahra Ghaznavi, 28, of Central Road, Wembley. She died on March 20 of a flesh-eating bacteria, known as necrotising fasciitis, and E. Coli.

She fell into a coma several days after delivering her healthy baby Sahar, now six-months-old, having suffered from diarrhoea.

She came to Britain from Afghanistan at the start of her pregnancy, speaking little English and had trouble getting ante natal care because she had not been in the country long enough.

She went to the Royal Free first in July last year suffering from vaginal bleeding, nausea, vomiting and abdominal pain. She subsequently went again in October.

An earlier report suggested the care she received before arriving at Northwick Park seemed to be below standard, probably because she was new in the country.

This week’s report found staff were not to blame for the three tragedies, but instead said there were “opportunities for better high-level clinical care in interpreting and reacting to apparently ‘minor’ symptoms.”

The trust has drawn up a list of changes it wants to make on the back of the report, including the introduction of a system to ensure midwives visit women who do not make their antenatal appointments.