Inquest continues into death of Chesterfield mum with rare condition – that consultants believed was “superficial”

The court heard that Jess, of Nelson Street in Chesterfield, died on May 14 2021 after giving birth to her daughter Phoebe at Chesterfield Royal Hospital.

Jess suffered from Klippel-Trenaunay Syndrome (KTS), a rare disorder that can lead to vascular malformation, organ abnormalities and an enhanced risk of deep-vein thrombosis – which itself can lead to pulmonary embolism in serious cases.

Jess had been prescribed a drug called Tinzaparin during an admission to Chesterfield Royal Hospital on April 21 2021 – which helps to reduce the risk of deep vein thrombosis and pulmonary embolism.

The following day, however, she was transferred to the Jessop Wing in Sheffield and this prescription was discontinued when she was discharged – and the court heard that she was not given the drug at any stage when she returned to Chesterfield Royal Hospital.

On May 13, Jess was seen at Chesterfield Royal Hospital by Doctor Dutta – a consultant with a background in obstetrics and gynaecology, who at the time was also the clinical director for obstetrics at the Chesterfield Royal Hospital Foundation Trust (CRHFT).

He told the court that he was in regular communication with Jess and her partner Jack about her condition. At around 10pm that evening, Dr Dutta made the decision to deliver, after noting that Phoebe’s growth was on the lower side and her heart was not beating consistently.

Dr Dutta said that he delivered Phoebe via caesarean section, describing the procedure as “very straightforward” and “reasonably quick.” It was only after Phoebe was delivered that Jess’ condition deteriorated.

He said that he noticed a “lack of blood” while closing Jess’ wound, and that within a matter of seconds, she had what appeared to be a fit and became unresponsive.

The court heard that a cardiac arrest team was called immediately – consisting of doctors and staff with expertise in resuscitation from across the hospital.

Dr Dutta said that he was aware of Jess’ KTS, but did not know that her course of Tinzaparin had been discontinued. He said that, however, neither of these factors would have affected his decision to undergo a caesarean –telling the court that he had to take the decision for Jess’ daughter.

Dr Dutta said that there is “no indication of a relationship between KTS and maternal death.” He told the court that, in 2017, only “16 papers on the syndrome had been published in English literature” – with none of these mentioning any links to maternal death. He did, however, agree that a discussion of the potential risks to pregnancy that might result from KTS should have occurred with Jess.

Doctor Gordon, who has been a consultant anaesthetist at Chesterfield Royal Hospital since 2017, was on-call the day that Jess died. She described getting the “worst phone call I have ever received” at around 00.30am from another doctor at the hospital. They told Dr Gordon that they were dealing with a case of maternal cardiac arrest, where they had not been able to restart the heart.

She then arrived at the hospital around half an hour later – and was the most senior anaesthetist in the theatre while efforts to resuscitate Jess were underway. She said that every member of staff had acted “very swiftly” in their efforts to keep Jess alive.

Dr Gordon told the court that she had heard of KTS before, but stated that the syndrome would have made no difference in terms of the approach to resuscitating Jess. She said that Jess’ collapse and her symptoms could have pointed to her suffering a pulmonary embolism, amniotic fluid embolism or anaphylaxis.

Dr Gordon said that she saw no signs of deep vein thrombosis – a major cause of pulmonary embolism – after examining Jess’ legs.

She also told the court that the only symptoms of anaphylaxis she could identify were low blood pressure and shortness of breath – and added that she did not see the usual asthmatic-type reaction that someone suffering this condition would present.

As part of her treatment for cardiac arrest, Jess was given shots of adrenaline – which are also used to treat anaphylaxis. Dr Gordon said that they used the “entire hospital’s supply of adrenaline” while attempting to revive Jess – which was the “most she had ever used” on a patient.

Dr Gordon also ruled out that Jess had suffered a bleed on her brain, and said that, in her opinion, the most likely cause of death was either pulmonary embolism or amniotic fluid embolism.

Initially, staff were reluctant to give Jess thrombolytic, or clot-busting medication – with Dr Gordon stating that it was feared this might “accelerate her death.” The court heard that she was, however, given these drugs at around 2.55am.

The team caring for Jess considered transferring her to another hospital, to potentially receive “very advanced” treatment – but decided that her condition was too unstable to risk transporting her elsewhere. Attempts to resuscitate Jess continued for several hours – but she was pronounced dead that morning.

The court also heard from Dr Parratt, the current clinical director for obstetrics at the CRHFT. She was at home on May 14 when she received a call telling her there had been a maternal death at the hospital. She travelled to the hospital to support staff – where efforts to resuscitate Jess were taking place.

She was asked whether the issue of Tinzaparin, and the decision by the team at the Jessop Wing to stop giving her the drug, should have been brought up at Jess’ subsequent appointments in Chesterfield.

Between April 16 and May 13, Dr Parratt said that Jess “probably” should have been on Tinzaparin – adding that it “does depend on who you ask.” She said that Dr Creswell thought so after her assessment – and that she would probably agree with her decision – but stated that it was a “bit of a grey area.”

Dr Parratt accepted that there were missed opportunities to spot the problem surrounding the discontinuation of Jess’ Tinzaparin – and said that the “majority of clinicians” at Chesterfield Royal Hospital would have restarted the prescription.

She also defended the decision not to check whether Jess was still taking the drug when she returned to the hospital after her admission to the Jessop Wing. Dr Parratt said that the dosage of this drug is determined by a patient’s body weight, but this dose does not change if they get heavier during their pregnancy – stating that the medication is safe to use long-term.

As such, she said there was “no particular expectation to monitor Tinzaparin regularly” – with staff tending to assume that women who were prescribed the drug would still be taking it. Dr Parratt did accept that it could have been made clearer to Jess that, when she was admitted to the hospital on April 21, the prescription of Tinzaparin was not just intended to last for the duration of her stay – adding that it was “reasonable that Jess thought this was the case.”

Dr Parratt told the court that she did not know whether staff discussed with Jess the risks around her pregnancy and KTS – including the increased chance of pulmonary embolism – and said that it would have been “reasonable” to do so.

Dr Parratt said that, in her understanding, Dr Creswell was aware of Jess’ KTS – but admitted that it was “disappointing” that the syndrome was not mentioned in her antenatal records. She added that it was a “fair criticism” that Jess’ notes did not highlight her enhanced risk of pulmonary embolism – due to KTS – for other staff members picking up her case.

She did stress, however, that she did not think KTS would have been considered a major risk of PE that early in Jess’ pregnancy – and that “KTS would not have justified any different treatment at any stage.” Dr Parratt added that “very limited evidence” indicates, for those with KTS, that there is a “small increased risk” of suffering a pulmonary embolism – with the chances of developing this condition rising by 8%.

The court heard that, according to Dr Parratt, Jess’ severe preeclampsia was “far more significant” in terms of the decision to prescribe her Tinzaparin – and that is “perfectly reasonable” for an otherwise healthy woman to have been prescribed the drug where here only other risk is preeclampsia.

She also told the family that they “should not necessarily be upset” about staff members googling rare conditions – adding that they were doing so because KTS is so uncommon, and that this was a quick way of getting information during an emergency.

A report commissioned by the Healthcare Safety Investigation Branch (HSIB) stated that there was a “belief that KTS was superficial among consultants at Chesterfield Royal Hospital.”

Dr Parratt addressed this finding, and agreed that “staff did not have much understanding of the impact of KTS.” She said, however, that Jess’ severe hypertension and preeclampsia – the latter of which was life-threatening – posed a much greater risk than her KTS, meaning that staff had to prioritise these conditions.

The court heard that no discharge letter was sent to Chesterfield Royal Hospital following Jess’ stay at the Jessop Wing – with Dr Parratt stating that they “would normally expect one.”

She said that Jess would have been able to provide some details from her admission to the Jessop Wing, and that the decision-making around her care was informed by a range of tests that were completed when she returned to Chesterfield Royal Hospital. Staff had, according to Dr Parratt, “prioritised Jess’ preeclampsia and the baby’s growth” – and “assumed they had the information they needed to go forward.”

Dr Parratt did admit that it would have been “helpful” for Dr Creswell and her team to enquire about the changes to Jess’ Tinzaparin prescription – as the court heard that medical records showed no contact with the Jessop Wing to request any details from her admission. She said that “all of us who are aware of Jess’ case will have learned from it and will make sure to get the information that we need.”

When asked about how staff the hospital could learn from Jess’ case, Dr Parratt said that KTS had already been discussed informally at a consultant’s meeting. The court heard that a full day of training had been scheduled for March, with a consultant travelling from London to address the management of rare conditions, including KTS, during pregnancy. Dr Parratt said that this will be attended by both junior doctors and consultants.

Dr Parratt also said that recent changes, unrelated to this specific case, would help to improve communications between different trusts. She highlighted the development of Maternal Medicine Networks – which are being set up to ensure that all women with significant medical problems during pregnancy receive timely specialist care and advice.

She added that within these networks, there will be a matron whose role is to communicate with neighbouring trusts regarding any crossover of high-risk pregnant patients.

Dr Parratt said that, although the HSIB report did not find any care concerns, a number of issues were raised that she felt were “unjust.” She stated her wish that there had been a better process of engagement with the HSIB team – including a system that would have allowed the trust to recommend staff members to be interviewed as part of the HSIB investigation.

The inquest into Jess’ death continues today (Wednesday, January 18).