Ilona Kazik, a 32-year-old first-time mother, died from a brain hemorrhage and pre-eclampsia days after giving birth. A coroner ruled that inadequate care by medics led to her death, as she was sent home twice from the hospital within 24 hours of delivery despite having high blood pressure and a low platelet count.
These critical medical issues were not recorded or communicated to staff. Believing her to be low-risk, she was administered a drug that further increased her blood pressure, which the coroner stated, on the balance of probabilities, contributed to her fatal brain bleed.
Ilona's first attendance at Luton and Dunstable University Hospital occurred when her waters broke. Despite her elevated blood pressure and low platelet count, she was advised to go home.
The coroner found this to be a significant omission, as her severe hypertension should have immediately classified her as high-risk. She later returned with a severe headache but was again sent home, with a missed opportunity to review her previous medical notes.
Hours after the birth of her son, Antony, Ilona experienced headaches, blurred vision, and vomiting before becoming unresponsive. A CT scan revealed a major brain bleed, and she was transferred to Addenbrooke’s Hospital, where life support was withdrawn on February 25, 2023.
The coroner concluded that multiple omissions and missed opportunities in her care had far-reaching consequences, though she could not definitively say the death could have been prevented. Ilona's husband, Rafal, is now raising their son alone and expressed his devastation, highlighting the importance of improved patient safety to prevent similar tragedies.
