Failure by staff at Chesterfield Royal Hospital contributed to death of young mum with rare condition, inquest finds

On Friday, January 27, assistant coroner Matthew Kewley concluded the inquest into the death of Jess Hodgkinson at Chesterfield Coroner’s Court.

Jess, of Nelson Street, Chesterfield, died on May 14 2021 at the Chesterfield Royal Hospital – shortly after giving birth to her daughter, Phoebe.

The coroner began by stating that he preferred the evidence of Professor Suvarna, who carried out Jess’ post-mortem, with regards to her cause of death.

Professor Suvarna – described by the coroner as an “independent expert” with a “vast amount of experience in complex autopsies” – said that her death was more likely than not to have been caused by a pulmonary embolism (PE) due to deep vein thrombosis (DVT).

He said that the risk of this would have been increased due to Jess’ Klippel Trenaunay Syndrome (KTS), and was in association with acute anaphylaxis – which may have been caused by an antibiotic. A background of severe systemic hypertension was also recorded.

The coroner said there was ‘collective disquiet” from the Chesterfield Royal Hospital clinicians who gave evidence – claiming that an amniotic fluid embolism (AFE) may have been the cause of Jess’ collapse. He stated, however, that he accepted Professor Suvarna’s evidence.

The coroner did not raise any issues regarding Jess’ treatment for hypertension at Chesterfield Royal – stressing that he felt the condition was “appropriately managed” with “evidence of good multi-disciplinary practice.”

Jess also suffered from a rare condition referred to as KTS. In their report concerning her death, the Healthcare Safety Investigation Branch recognised that little is known about KTS and its link with pregnancy – but it does carry an increased risk of developing DVT and PE.

The court heard evidence from Dr Stratton, a consultant and obstetrics lead at the Jessop Wing in Sheffield, about how a clinician should approach the issue of a patient having a rare disorder.

He explained that during the clinician’s early assessment of the expectant mother, they are required to consider the rare disorder, carry out any necessary research, determine whether the condition will impact on the care to be provided during pregnancy and record the clinical assessment within the patient’s notes.

A community midwife and pharmacist had both made early entries in Jess’ notes, recognising the increased risk of DVT/PE that arose from KTS. The coroner said that, after reviewing her hospital records, there was occasional reference to KTS – but could not find any evidence of a clinician documenting that they had specifically considered KTS and how it might impact on Jess’ pregnancy.

He added: “I was unable to find any evidence of clinicians considering the increased DVT/PE risks associated with KTS when assessing Jess’ venous thromboembolism risk. It appears that the process that Dr Stratton described above (namely assessing whether the rare disorder will impact the pregnancy) did not take place. Dr Parratt (clinical director for obstetrics at Chesterfield Royal) described it as ‘disappointing’ that there was nothing documented in the notes about a consideration of the impact of KTS on Jess’ pregnancy.

“Looking at the evidence as a whole, I am satisfied that there was insufficient consideration of the impact that KTS might have had on Jess’ pregnancy. It is notable that the HSIB investigation concluded that staff had a belief that KTS was ‘superficial’.

“During the inquest, I was repeatedly told that KTS ‘wouldn’t have made a difference’. The difficulty with that point, however, is that I could not find any evidence of staff having properly considered KTS in the first place in order to have reached the conclusion that it was not relevant to Jess’ pregnancy.”

The coroner also discussed a concern raised by Jess’ family at the outset of the inquest – that staff at Chesterfield Royal had googled KTS to find out more about the condition.

He said: “I heard evidence during the inquest that staff had ‘googled’ KTS. It is unrealistic to suggest that every clinician should instinctively know about KTS and the associated increased risk of DVT/PE. That is simply not the reality of clinical practice.

“Whilst I understand that staff ‘googling’ KTS would have been upsetting for Jess’ family, I would not accept that there is any legitimate criticism to be made of staff researching KTS in this way. The issue is about the lack of evidence of any analysis of the potential impact that KTS might have had on the pregnancy.”

The coroner said that, however, the issues relating to the assessment of Jess’ KTS had not caused her death. He said that there was no evidence that this condition would have warranted the prescription of medication to tackle DVT or PE at an earlier stage – and that ultimately, Jess was prescribed this drug anyway.

On 21 April 2021, Jess presented to the Chesterfield Royal Hospital with increased blood pressure. There were concerns that she was suffering from pre-eclampsia, and that it might be necessary to deliver her baby early.

The court heard that Dr Creswell prescribed a dose of an anticoagulant medication called tinzaparin, due to the increased risk of clotting. This decision was informed by Jess’ possible pre-eclampsia, and Dr Creswell’s evidence was that she intended for Jess to continue taking tinzaparin until birth in order to reduce the risk of clots forming.

The coroner said that it was “unhelpful”, however, that Dr Creswell’s notes from April 21 did not reference her plans for this prescription to continue until birth, or any discussion with Jess regarding the plan for this medication.

Jess was then transferred to the Jessop Wing of the Royal Hallamshire Hospital in Sheffield on April 22 2021. She was moved as staff were concerned that birth might be imminent – and the Jessop Wing had the facilities to care for such a premature baby.

On her admission to Sheffield, the ward round notes recorded that Jess was receiving tinzaparin. Jess was given a different anticoagulant medication called dalteparin during her stay in Sheffield, but on her discharge from Sheffield, Jess was not prescribed any form of ongoing anticoagulant medication.

The court heard that Dr Creswell was completely unaware that Jess was no longer receiving any anticoagulant medication after her discharge from Sheffield. The coroner said she gave “very clear evidence” that, if she had known that Jess was no longer receiving this prescription, she would have restarted it.

Dr Stratton said that if a clinician referring a patient intended that they would receive ongoing medication until birth, that information needed to be communicated to Sheffield as part of the transfer.

After reviewing Jess’ records, Dr Stratton could find no evidence that any information about Dr Creswell’s plan for ongoing medication to continue until birth had been communicated to Sheffield by the team in Chesterfield.

The coroner said: “I find as a fact that there was a failure to inform Sheffield of Dr Creswell’s plan for ongoing prophylactic anticoagulant medication. I also find as a fact that because of the failure to transfer this information, staff at Sheffield were, understandably, unaware of Dr Creswell’s intentions – which explains why Sheffield did not ensure that Jess received ongoing prophylactic anticoagulant medication when she was discharged from Sheffield back to Chesterfield.

“It transpires, therefore, that contrary to how it initially appeared during the inquest, nobody in Sheffield had ‘stopped’ Dr Creswell’s prescription for Tinzaparin at all – the issue was that the Sheffield team were never told about the plan for ongoing prophylactic anticoagulant medication until birth in the first place.”

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The court heard from clinicians at Chesterfield Royal that they would expect to receive a discharge letter when a patient is transferred back into their care – and they added that they had never received one from the Jessop Wing.

The Jessop’s team did take steps to make contact with the community midwife and the GP Practice, but Dr Stratton appeared to accept that there was no direct communication back to Dr Creswell in Chesterfield.

The coroner said: “Dr Stratton told the court that in circumstances where a patient is transferred to Sheffield and then discharged back to the original trust, there is no formal process for communicating information back to the clinicians at the original trust.

“Whilst this may raise a wider issue about communication, I am satisfied that it had no material bearing on Jess’s care. This is because Sheffield were never told about the plan for ongoing Tinzaparin in the first place, which meant there was no expectation on Sheffield to communicate anything about tinzaparin back to Chesterfield.”

In the weeks following her discharge from Sheffield, Jess continued to receive care in Chesterfield. On 30 April 2021 Jess attended an appointment with Dr Creswell, who said that she remained unaware that Jess was no longer taking Tinzaparin, and would have restarted her prescription if she had known.

The coroner said: “I find as a fact that following the discharge from Sheffield, staff at Chesterfield did not identify that Jess was no longer receiving the prophylactic anticoagulant medication.

“I find as a fact that there were missed opportunities following the discharge from Sheffield for staff at Chesterfield to identify that Jess was no longer receiving the prophylactic anticoagulant medication. I find as a fact that staff in Chesterfield should have identified that Jess was no longer receiving the prophylactic anticoagulant medication.

“I find as a fact that the Tinzaparin would have been restarted had Dr Creswell known that Jess was no longer receiving it. I also find as a fact that Jess was not asked about whether she was still taking the anticoagulant medication (which was a further missed opportunity to identify the issue).

“After considering the totality of the evidence, I find as a fact that on the balance of probabilities, the failure to ensure that Jess continued to receive the intended daily prophylactic dose of Tinzaparin made a more than minimal, negligible or trivial contribution to her death on 14 May 2021.

“It is more likely than not that the deep vein thrombosis which led to the pulmonary embolism would not have occurred had Jess continued to receive the daily prophylactic dose of Tinzaparin up until birth.

“It is important to recognise, however, that this does not necessarily mean that Jess would have survived on 14 May 2021 had the failure not occurred.”

The coroner stated that he did not believe neglect had contributed to Jess’ death. He said that, in order to find this, there has to be evidence of a “gross failure” in care, and the “act or omission in question must be such that the deceased would have survived had the failure not occurred.”

He asserted that, even if Jess’ Tinzaparin prescription had continued and prevented a PE, she might still have died from the acute anaphylaxis. He said: “I find, therefore, that it is not possible to say that Jess would have survived if the prophylactic dose of Tinzaparin had continued as Dr Creswell intended. It follows that I do not find that Jess’ death was contributed to by neglect.”

In his narrative conclusion, the coroner said: “Jess died on 14 May 2021 due to a pulmonary embolism that arose from a deep vein thrombosis (the risk of this was increased by the KTS) as well as acute anaphylaxis of unknown cause. There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess’ death on 14 May 2021. “

He added that, “whilst this inquest has identified issues in the care provided to Jess during her pregnancy, it must also be noted that there was evidence of good quality care provided by the team in Chesterfield. In particular, I noted the exemplary efforts made by all of the clinicians who worked tirelessly to save Jess on 14 May 2021.

“I will be issuing a Prevention of Future Death Report and I shall share this with Jess’ family in due course.

“I conclude by extending my condolences to all of Jess’ family and friends. I wish to record my appreciation for the dignified and composed way in which Jess’ family conducted themselves throughout the inquest. They all demonstrated restraint and dignity in spite of the tragic circumstances of Jess’ death.”