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The ‘extremely cut’ teenager sent home from hospital died a day later

A girl collapsed and died a day after being discharged from hospital without a formal diagnosis and no prescribed treatment, a coroner has heard.

Lilly Proctor, 13, was taken to the Emergency Department at Pinderfields Hospital in Wakefield with complaints of breathing difficulties and chest pains. Of the five doctors who saw Lilly before she died, only one of them knew about the family history of blood clots. Lilly was said to have a strong family history of thromboembolic disease (a condition in which clots form in the deep veins).

Doctors variously believed her symptoms in hospital were cardiac in origin, to anxiety, or caused by an infection or due to pneumonia, an inquest heard.

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Lilly died on 3 April 2022 at Pinderfields Hospital after collapsing at home. A post mortem examination gave her cause of death as 1a, massive pulmonary thromboembolism, 1b, deep vein thrombosis and 1c, pathogenic PROS variant 1 (a genetic disorder).

Post mortem findings were consistent with Lilly having developed a series of non-fatal pulmonary thromboembolisms (blood clots in the lungs) before her final collapse.

An inquest into her death heard from an independent expert paediatrician, who said features on an electrocardiogram (heart test) that doctors thought were attributable to Lilly’s age were potentially indicative of a number of conditions, such as a heart strain and pulmonary embolus.

West Yorkshire Coroner Oliver Longstaff, in a report into preventing future deaths, wrote: “Lilly was discharged from hospital on 2 April 2022 without a formal diagnosis and no prescribed treatment. She failed to complete an exercise test asking her to walk a short distance around the ward, although her heart rate (which remained above 100 bpm throughout her admission) was recorded as the same at the start and end the test.”

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The coroner said the combination of Lilly’s EKG and her extreme shortness of breath would have warranted an echocardiogram and 24-hour EKG, but added: “It cannot be said on the balance of probabilities that any step taken as an alternative to discharging Lilly on April 2, 2022 would have prevented the tragedy of her terminal collapse the next day.”

Mr Longstaff sent his report to the National Institute for Health and Care Excellence and the Royal College of Paediatrics and Child Health on the lack of screening tools specific to children to detect pulmonary thromboembolism.

He wrote: “The rarity of thromboembolism in children raises the concern that, without access to resources similar to those available when dealing with the adult population, clinicians working with children may be at a disadvantage in diagnosing and treating the condition, to the obvious potential detriment. among their patients”.

The coroner also sent a copy of his report to Mid Yorkshire Teaching NHS Trust.

In a statement, Richard Robinson, Chief Medical Officer at Mid Yorkshire Teaching NHS Trust, said: “We would like to offer our deepest condolences to Lilly’s family for the unimaginable pain and suffering caused by Lilly’s death.

“We accept the coroner’s findings and have implemented a number of measures within our trust Pediatric Services following the lessons learned from the tragic circumstances of this case.

“As noted in the Coroner’s findings, cases of pulmonary thromboembolism in children are rare and there is an absence of national clinical tools and guidance available to help detect pulmonary thromboembolism in children. at NICE and the Royal College of Paediatrics and Child Health’.