Coroner expresses concerns over failure at Chesterfield Royal Hospital that contributed to death of young mum

The inquest ruled a failure by staff to check her medication had contributed to her death.

Jess, 26, died on May 14, 2021, shortly after giving birth to her daughter Phoebe. An inquest heard that she wasn’t given the correct medication and died from a pulmonary embolism.

At the inquest, held in January, assistant coroner Matthew Kewley said there was a “failure” to ensure Jess – who was engaged to Jack Knowles – had received blood thinners up until the birth of her daughter.

The pregnancy was deemed high-risk due to severe hypertension whilst Jess also had a rare condition called Klippel-Trenaunay Syndrome (KTS) which created an increased risk of developing deep vein thrombosis.

Mr Kewley has now written to Chesterfield Royal Hospital as part of a prevention of future deaths report.

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He said whilst it was understandable some staff were unaware of the potential implications of KTS but he didn’t see any evidence of any consultant documenting the potential impact in Jess’ medical notes.

He added: “I heard evidence from Jess’ consultant that she intended that tinzaparin would be taken by Jess up until birth. When Jess was discharged from Sheffield back into the care of Chesterfield, nobody in Chesterfield identified that Jess was not receiving the tinzaparin which the consultant told the inquest ought to have been in place until birth.

"When Jess was discharged from Sheffield on 26 April 2021, she was not given tinzaparin because the team in Sheffield were unaware of this plan. I am concerned, therefore, about the quality and adequacy of the information handed over to Sheffield at the point of Jess being transferred into their care.

"I am concerned that there was no process in place in Chesterfield to follow up and find out what had happened during Jess’ short period under the care of Sheffield. Had efforts been made to liaise with the team in Sheffield, the tinzaparin issue might have been identified.”

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As previously reported, the inquest heard a number of tributes from Jess’ family members.

Grant Finney – Jess’ uncle – spoke on behalf of the family. He said that he and Jess were “best friends” and she was “deeply adored” by her loved ones. She grew up in Chesterfield and was an “outgoing, supportive person” who loved to dance – adding that he “couldn’t drag her home” when they went out together.

He said that Phoebe, although born very prematurely, was doing very well, and that she was a “little light for all of us” and had “kept us all going” in the aftermath of Jess’ death.

The hospital has 56 days to outline action proposed in response to concerns raised by the coroner.

Chesterfield Royal Hospital NHS Foundation Trust has been approached for comment. At the time of the inquest they said, in a statement reported by the BBC, they would ‘review the Prevention of Future Deaths Report and will look to ensure we work through all recommendations’.