“I heard evidence from Jess’ consultant that she intended that tinzaparin would be taken…”
Dated 26 May 2023, from the coroner for Derby and Derbyshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 21 Jul 2023. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated26 May 2023
- Deadline21 Jul 2023
- Published on judiciary.uk2 Jun 2023
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Chesterfield Royal Hospital NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Jul 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) 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) 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) 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) 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2023-0174
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use