A coroner ruled that a woman who died shortly after giving birth to her daughter did not receive the proper medication.
Jess Hodgkinson, 26, of Chesterfield, died in 2021 of a pulmonary embolism.
Assistant coroner Matthew Kewley stated that there was a “failure” to ensure Ms Hodgkinson received blood thinners up until the birth.
Chesterfield Royal Hospital NHS Trust stated that it “recognizes and respects the findings” of the coroner.
Ms Hodgkinson had a high risk pregnancy due to severe hypertension, according to the Coroner’s Court in Chesterfield.
She also had Klippel-Trenaunay Syndrome (KTS), which increased her chances of developing a deep vein thrombosis.
The inquest found no documented evidence that clinicians in Chesterfield had properly considered the impact of KTS on Ms Hodgkinson’s pregnancy. Mr Kewley claims that this did not contribute to her death.
The inquest heard that on April 21, 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting.
During the inquest, the consultant stated that Ms Hodgkinson would continue to receive anticoagulant medication on a daily basis until she gave birth.
Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a “failure to communicate” the medication plan, according to Mr Kewley.
After being discharged, clinicians in Chesterfield “failed to identify” Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling.
On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson’s baby was born.
But after delivery, Ms Hodgkinson went into cardiac arrest and later died.
In his concluding remarks, Mr Kewley said: “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.
“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.”
“We wish to offer our sincere and heartfelt condolences to the family, and everybody connected and concerned by the tragic loss of Jess Hodgkinson,” said Krishna Kallianpur, chief nurse at Chesterfield Royal Hospital NHS Foundation Trust.
“As a trust we will be reviewing the Prevention of Future Death Report and will look to ensure we work through all recommendations and findings with due diligence.”
source:https://ghanaianexpress.com
