Communication concerns raised over mum's death

"Confused" lines of communication between two NHS trusts "present a risk" to the care of future patients, a coroner has warned after a new mother's death.

Gemma Robins, from Hove, died 40 days after the birth of her daughter in 2024. Her family called her "loyal, protective and caring".

Senior coroner Penelope Schofield raised concerns about communication between specialists at the Royal Sussex County Hospital in Brighton, where she was being treated, and the Royal Surrey County Hospital, who advised on her care.

A Royal Surrey spokesperson said it accepted communication "presented challenges" and committed to improving, while University Hospitals Sussex said new systems had been introduced.

Gemma's parents, Paul and Liza Robins, said: "Gemma was our beautiful daughter and, had she been given the chance, we are sure she would have made an incredible mother.

"We welcome the coroner's decision to issue prevention of future deaths reports following Gemma's inquest.

"We still think of Gemma every day and will continue to campaign for change to ensure that lessons are learned from the evidence heard at her inquest."

In a prevention of future deaths report, Schofield said she heard that modes of communication between teams, including text, email and telephone, "can be extremely challenging and prone to miscommunication when multiple teams were involved with a patient".

She added that the inquest revealed that there were "confused lines of communication between clinicians" at the two trusts.

A separate prevention of future deaths report, addressed to University Hospitals Sussex NHS Foundation Trust, says that there were not adequate safeguards in place to ensure that basic checks during antenatal appointments were carried out.

University Hospitals Sussex NHS Foundation Trust, which runs the Royal Sussex and Worthing Hospitals, said in its response to the report that it would use Robins' case to help train maternity staff.

An inquest into Robins' death in July heard how she was admitted to Worthing Hospital for persistent vomiting, and it was decided her baby girl would be delivered by Caesarean section.

Robins, 30, was transferred to the intensive care unit at the Royal Sussex Hospital the next day, where she went on to develop internal bleeding.

Lawyers representing her family said that after delays caused by poor communications between the staff at the hospitals, she had a procedure to block the bleeding vessel, and was transferred to the Royal Surrey County Hospital, in Guildford.

There Robins underwent emergency surgery, but doctors later concluded there were no further surgical options.

She died on 13 June 2024, from a serious liver condition and inflammation of the pancreas.

The inquest found that there was a "missed opportunity" at an antenatal appointment in April 2024 to investigate possible pre-eclampsia.

Dr Bill Jewsbury, medical director at the Royal Surerey NHS Foundation Trust, expressed his "deepest condolences" to Robins' family.

He added: "While we did everything we could for Gemma and the Trust's care was not subject to criticism, I recognise that communication between the hospitals presented challenges.

"We are committed to improving this through embedding a new and more robust system."

A University Hospitals Sussex spokesperson said: "We are deeply sorry for the loss of Gemma, and our thoughts remain with her family and everyone who loved her."

They added that the trust had responded fully to the coroner about further changes since her findings.

"Since Gemma's death, we have introduced new shared communication systems with specialist tertiary hospital centres, updated clinical guidelines, and we will include the learnings from Gemma's case in mandatory staff training," they added.

"We remain committed to continually improving the safety and quality of the care we provide."

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