A lack of medication contributed to Jess Hodgkinson's death
Posted on 6th February 2023
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.A coroner has ruled that a woman who died soon after giving birth to her daughter was not given the correct medication.
Jess Hodgkinson, age 26, passed away from a pulmonary embolism in 2021.
Assistant coroner Matthew Kewley said "there was a failure to ensure Ms Hodgkinson received blood thinners right up until the birth."
Chesterfield Royal Hospital NHS Trust said it "recognises and respects the findings from the coroner."
Chesterfield Coroner's Court heard that due to severe hypertension, Ms Hodgkinson had a high-risk pregnancy. She also had a rare condition known as Klippel-Trenaunay Syndrome (KTS), which increased the risk of her developing a deep vein thrombosis.
The inquest found that there was no documented evidence of clinicians in Chesterfield properly considering the impact of KTS on Ms Hodgkinson's pregnancy. However, according to Mr Kewley, this did not contribute to her death.
On April 21, 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting. The consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth.
Mr Kewley said Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan.
In his ruling, the coroner stated after being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication.
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.
However, shortly after giving birth, Ms Hodgkinson went into cardiac arrest and later died.
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."
The chief nurse at Chesterfield Royal Hospital NHS Foundation Trust Krishna Kallianpur said, "We wish to offer our sincere and heartfelt condolences to the family, and everybody connected and concerned by the tragic loss of Jess Hodgkinson."
"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."
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