A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled.
Jess Hodgkinson, 26, from Chesterfield, died 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 Ms Hodgkinson had a high risk pregnancy due to severe hypertension.
She also had a rare condition known as Klippel-Trenaunay Syndrome (KTS), which created an increased risk of her developing a deep vein thrombosis.
‘Failure to communicate’
The inquest found there was no documented evidence of clinicians in Chesterfield having properly considered the impact that KTS may have on Ms Hodgkinson’s pregnancy. However, this did not contribute to her death, Mr Kewley said.
On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard.
During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth.
Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a “failure to communicate” the medication plan, Mr Kewley said.
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.”
Krishna Kallianpur, chief nurse at Chesterfield Royal Hospital NHS Foundation Trust, 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.”