Coroner warns of hospital communication risks after mother's death

A senior coroner has raised concerns regarding communication failures between hospitals following the death of 30-year-old Gemma Robins. Penelope Schofield, the senior coroner for West Sussex, Brighton and Hove, stated that “confused” lines of communication between clinicians at the Royal Surrey NHS Foundation Trust and University Hospitals Sussex NHS Foundation Trust “present a risk to the care provided to future patients.”

An inquest into Ms. Robins’ death revealed a “missed opportunity” during an antenatal appointment in April 2024 to investigate potential pre-eclampsia. The coroner noted that blood tests might have identified abnormal liver function, which could have prompted an earlier hospital admission.

Following a Caesarean section, Ms. Robins was transferred to the intensive care unit at Royal Sussex Hospital, where she developed internal bleeding. Lawyers for the family reported that delays occurred due to poor communication between staff at Royal Sussex Hospital and the specialist team at Royal Surrey County Hospital. Despite undergoing emergency surgery at the Guildford facility, Ms. Robins died on June 13, 2024, from a serious liver condition and inflammation of the pancreas.