Woman, 29, died from blood clot caused by the Pill

A 29-year-old woman died from a pulmonary embolism caused by the contraceptive pill she was taking to manage endometriosis, an inquest has found.

Sitting at Wakefield Coroner's Court, Oliver Longstaff determined that Chloe Alicia Ellis's life could have been saved if information she gave to the NHS 111 service had been passed to the hospital that treated her.

Ms Ellis died on 3 September 2024 in Leeds General Infirmary after collapsing at home three days after she called 111. She was initially diagnosed with a viral illness and discharged from hospital.

Mr Longstaff said if the NHS 111 information had been available to the Dewsbury District Hospital "the suspicion of a pulmonary embolism would have been visible".

The inquest on 9 June found she had a pulmonary embolism as a result of taking the oral contraceptive pill Yasmin.

Mr Longstaff said: "Had a history of her oral contraceptive use been obtained when Chloe attended a local hospital emergency department on 31 August 2024, she would have been given anticoagulation medication and undergone tests that would have revealed the pulmonary embolism.

"She would have received effective treatment for the pulmonary embolism and, on the balance of probabilities, would not have died three days later."

According to the coroner, Ms Ellis had been taking Yasmin to manage her endometriosis since September 2023.

On 31 August she contacted NHS 111 online after experiencing chest and back pain and breathlessness, informing them of her oral contraceptive use.

The online assessment advised her to attend a local emergency department, having concluded via the algorithm that she had a suspected pulmonary embolism.

But the assessment did not tell Ms Ellis she had a suspected pulmonary embolism, which occurs when a blood clot blocks a vessel in the lung.

She attended Dewsbury District Hospital where an inadequate history was taken and staff did not have access to the information given to NHS 111.

Three days later she collapsed at home and died at Leeds General Infirmary on 3 September.

According to the coroner, it is possible for the outcomes of NHS 111 online assessments to be made accessible to emergency departments, but the West Yorkshire Integrated Care Board (ICB) had not commissioned accessibility to NHS 111.

Mr Longstaff said: "The availability of NHS 111 online assessments to clinicians in emergency departments may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in emergency departments."

A spokesperson for West Yorkshire ICB said the trust was working to understand what changes were needed going forward.

They said: "We are very sorry to hear about what happened to Chloe, and our sincere condolences go to her loved ones.

"We have been reviewing the points raised by the coroner and we are working with all our relevant partners to understand the learning and the current arrangements to establish what changes are required in order to prevent similar losses in future."

Mr Longstaff has written to the ICB with his findings in a Prevention of Future Deaths report.

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