THE family of a young woman who died of the same rare condition as her mum and aunt is preparing to sue Hampshire health chiefs.

Today coroner Keith Wiseman concluded a three-day inquest by saying Kelly Hutchings died from "a cerebral haemorrhage in the context of a systemic failure to provide the specialist advice during her pregnancy".

The inquest heard that the 22-year-old was never referred to a gynaecology specialist because of a clerical mix up.

Giving his verdict Mr Wiseman said: "A specialist caring for Kelly during her pregnancy would almost by definition have had a far greater chance of helping her through her pregnancy successfully that could have been contemplated in an earlier generation.

"The tragedy of this case is that she never received that help."

During the inquest at Southampton Coroner's Court evidence was heard from the head of midwifery at Portsmouth Hospitals NHS Trust, Donna Ockenden, consultant neurosurgeon Owen Sparrow, and Professor Michael de Swiet, who produced a damning report saying her death could have been averted.

In his independent review, Professor de Swiet told the inquest that if Kelly had been given an anti-coagulating drug in time, the outcome could have been very different.

He said: "I think it's possible, if people had been more aware of her family history, then she might just have had the neuro-imaging earlier, which might just have led to Heparin treatment, which might just have saved her life.

"It is quite amazing to me that somebody could have two close relatives who have died in pregnancy and not been referred to a specialist."

Kelly, from Fareham, died of cerebral venous thrombosis at Southampton General Hospital before she had the chance to see newborn daughter Nikita, who was delivered by caesarean section in November 2005.

The two-year-old was born severely disabled with cerebral palsy, brain damage and blindness. After the hearing, step-mum Merissa, from Gosport, said: "We came here, Kelly's dad and I to have some serious questions answered on why 20 years after he lost his wife he lost his daughter in this day and age, and the result we got was what we wanted."

Portsmouth Hospitals NHS Trust medical director Graeme Zaki said that the trust was reopening its internal investigation to stop the same situation arising again.

He said: "The administration of all ante-natal bookings is now done at St Mary's Hospital so that they are centrally co-ordinated. The trust has worked with GPs to have a more streamlined booking system which recognises high-risk patients."