Jessica Hodgkinson
26 May 2023 · Coroner Matthew Kewley · Derby and Derbyshire
The coroner's concerns
1. failure to continue tinzaparin after discharge
“I heard evidence from Jess' consultant that she intended that tinzaparin would be taken by Jess up until birth. When Jess was discharged from Sheffield back into the care of Chesterfield, nobody in Chesterfield identified that Jess was not receiving the tinzaparin which the consultant told the inquest ought to have been in place until birth.”
2. information gap in medication plan handover
“I heard evidence that there was no communication to the team in Sheffield that Jess' consultant in Chesterfield intended that she should continue to receive tinzaparin until birth. Therefore, when Jess was discharged from Sheffield on 26 April 2021, she was not given tinzaparin because the team in Sheffield were unaware of this plan. I am concerned, therefore, about the quality and adequacy of the information handed over to Sheffield at the point of Jess being transferred into their care.”
3. absence of follow-up on transferred patient care
“I heard evidence that following Jess' discharge from Sheffield on 26 April 2021, Chesterfield did not receive any communications from Sheffield about Jess' care during her time in Sheffield. I am concerned that there was no process in place in Chesterfield to follow up and find out what had happened during Jess' short period under the care of Sheffield. Had efforts been made to liaise with the team in Sheffield, the tinzaparin issue might have been identified.”
4. lack of documented KTS pregnancy risk assessment
“I heard in evidence that some staff were unaware of KTS and its potential implications for pregnancy. This was understandable. However, I did not see evidence of any consultant having properly considered and then documented in Jess' notes the potential impact that KTS might have had on Jess' pregnancy.”
Responses
No published response was found on judiciary.uk.