Jess Hodgkinson: Sheffield doctor’s evidence heard at inquest into tragic death of new mum

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

Her pregnancy was complicated by 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.

Chesterfield Coroners Court heard that 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. It was intended that Jess would remain on this drug until she was ready to give birth.

The following day, however, she was transferred to the Jessop Wing in Sheffield. When she was eventually discharged on April 26, this prescription for Tinzaparin was discontinued – and she was not given the drug again on any subsequent visits to Chesterfield Royal Hospital.

The court heard evidence from Dr Stratton, a consultant and obstetrics lead at the Jessop Wing in Sheffield –where Jess spent five days shortly before her death. He told the court that this was the first case of KTS that he had ever come across in his career.

Dr Stratton said that Tinzaparin was included on Jess’ list of medications when she was transferred from Chesterfield to Sheffield. He added that these transfer notes, which may have been from a midwife, included no documents from Dr Creswell – the consultant at Chesterfield Royal Hospital who was responsible for the package of care that Jess received.

He told the court that Dr Creswell’s plan to continue Jess’ Tinzaparin prescription until she gave birth “was not communicated to us” – and stated that he felt this was something which should have been documented explicitly.

Dr Stratton said that, when Jess was discharged, there was no “active decision” to stop her prescription. He stated that, as there was no documentation to highlight that Tinzaparin was for anything other than Jess’ inpatient stay, it was not continued after she left the Jessop Wing.

He then addressed the issue surrounding Jess’ inpatient discharge summary. Dr Creswell told the court previously that the cancellation of her Tinzaparin prescription was not communicated to her – and that she would have reinstated this had she been aware.

Dr Stratton confirmed that an email had been sent regarding Jess’ high blood pressure to a community midwife. He said, however, that there was no formal notification of her transfer back to the care of Chesterfield Royal Hospital.

He then told the court that consultants at neighbouring trusts will sometimes phone each other when a patient is transferred between them – but that this was a “courtesy” rather than a policy, and not something that would necessarily be documented.

Dr Stratton added that the need for a formal transfer between consultants would be determined on a case-by-case basis – usually taking place for patients with very complicated conditions

He agreed that there was a gap in terms of transferring details when Jess went back to Chesterfield, but said that he felt there was “very little information that needed to be sent.”

Dr Stratton said that the team at the Jessop Wing were told they may have to deliver Jess’ baby early due to pre-eclampsia – and this meant their job was to stabilise that condition and prepare for possible delivery. He added that Jess was not referred for management of her KTS, and that, had this been the case, it would have changed their management of her care.

He stated that he felt it was the correct decision to transfer Jess to the Jessop Wing, that staff there had the necessary information from her referral to decide whether to deliver her baby, and that the handover from Chesterfield regarding her pre-eclampsia was adequate.

He also said that Jess was only at the Jessop Wing for a short period, and it would be assumed that the plan of care for the rest of her pregnancy – set by the team in Chesterfield – would still be there going forward.

Dr Stratton said there were “lots of concerns nationally about the sharing of information across trusts, mostly because most trusts use different systems.” He added that work was underway across the Sheffield Teaching Hospitals NHS Foundation Trust to improve their methods for processing and sharing information – including the rollout of a new IT system.

After being questioned by Mr Harmel, representing Jess’ family, Dr Stratton agreed that, if Jess had continued taking Tinzaparin between her discharge from the Jessop Wing and when she gave birth, this would have reduced the risk of developing deep vein thrombosis and pulmonary embolism. He did, however, add that this would have been the case for any pregnant woman who had developed a blood clot.

Making his final submissions, Mr Harmel said there were two issues that Assistant Coroner Matthew Kewley needed to determine – the first being Jess’ cause of death.

He recalled the evidence given by Professor Suvarna, who performed Jess’ post-mortem. Mr Harmel said that he had, on the balance of probabilities, highlighted that the most likely cause of death was a combination of pulmonary embolism and acute anaphylaxis – with a secondary cause of deep vein thrombosis and complicating KTS.

He said that Dr Creswell had accepted that Jess should have been on Tinzaparin between April 26 and May 13. He went on to add that Dr Stratton had stated, on the balance of probabilities, that this would have made a difference in reducing the chances of Jess developing deep vein thrombosis and pulmonary embolism.

Mr Harmel said that the prescription of Tinzaparin in these circumstances was “fairly basic”. He went on to state that the “failure to consider that” when Jess attended Chesterfield Royal Hospital on April 30 – and the issues surrounding the sharing of details around this prescription – constituted a “gross failure” in Jess’ care.

Ms Rowbottom made the final submission on behalf of the Chesterfield Royal Hospital NHS Foundation Trust (CRHFT). She said that Doctors Dutta, Creswell and Parratt had all stated their belief that, on the balance of probabilities, amniotic pulmonary embolism was a more likely cause of death.

She also said that there was no evidence of deep vein thrombosis or pulmonary embolism when Dr Gordon was attempting to resuscitate Jess – nor was any evidence discovered during the post-mortem exam.

Ms Rowbottom added that Jess was treated for pulmonary embolism during the efforts to revive her – and highlighted Dr Parratt’s difficulty in understanding how this treatment, if she had suffered this, did not lead to any improvement in her condition.

Addressing what might be learned from this case, Ms Rowbottom said that the CRHFT was in the process of fitting into the new Maternal Medicine Network – which includes measures to improve movement of information and patients between trusts. She said that, although “in its infancy”, these changes were not “fanciful” and were underway.

The assistant coroner is expected to issue his conclusion the week beginning January 23.