A coroner has criticised an NHS trust over the deaths of two new mothers with herpes.
Kimberley Sampson, 29, and Samantha Mulcahy, 32, died in 2018 after having caesarean sections six weeks apart by the same surgeon at hospitals in Kent.
Their families have been waiting five years for answers on how they came to be infected with the virus, which can cause sores around the mouth or genitals.
Catherine Wood, Mid Kent and Medway coroner, said Sampson could have been given an anti-viral treatment sooner.
Wood added that in Mulcahy’s case “suspicion should have been raised” given the knowledge among staff from Sampson’s earlier death.
At the inquest hearing at Kent County Hall in Maidstone on Friday, Wood said: “The earlier treatment is given, the better the outcome.”
The coroner ruled out human culpability of any of the medical staff involved in the case and said it was “unlikely” for the surgeon to be the cause of the herpes infection found in both women.
She said: “I can’t find he was a carrier without some proof of evidence.”
The coroner subsequently ruled out conclusions of unlawful killing and neglect, which lawyers for the women’s families had argued for.
She is expected to give narrative conclusions for both women on 26 July.
Both hospitals where the women died are run by the East Kent hospitals university NHS trust (EKHUT).
Sampson gave birth to her second child, at the Queen Elizabeth the Queen Mother hospital in Margate in May 2018, and died at the end of the month in a London hospital.
In July 2018, first-time mother Mulcahy died at the William Harvey hospital in Ashford, Kent.
The coroner said: “This is a rare but often fatal disease and more needs to be done to raise awareness of it.
“All of the evidence suggests early recognition is more likely to raise a positive outcome.”
The virus, HSV-1 or herpes simplex, is a common infection but if contracted after giving birth, it is “a potentially fatal disease” Woods said.
The inquest previously heard in April how the surgeon, who cannot be named for legal reasons, could have been a potential source of the infection.
But the surgeon told the inquest his hands were fully scrubbed, double gloved and he was wearing a mask during procedures.
He also said he had no lesions and was not infected, though he had not been tested.
The coroner said those involved who suggested it was the surgeon were trying to “plug the gap” with a possible explanation but she ruled it was unlikely and that “statistical coincidences can occur”.
The hearing also heard a legal challenge from the BBC and the PA news agency to lift the anonymity order applied for by the trust to stop the surgeon being named.
EKHUT argued its anonymity order was to protect the reputation and mental health of its staff member from what it claimed would be damaging media reports of the case, but the media’s bid argued the fears for the surgeon were speculative.
Wood also adjourned her decision over the surgeon’s anonymity until the same hearing on 26 July.
