A MUM-OF-TWO died of a massive blood clot just 20 minutes after being sent home from hospital, an inquest has heard.
Healthy athlete Rachel Pinker, 33, collapsed on the kitchen floor following a "perfect storm" of circumstances.
Rachel was hit by periods of breathlessness last summer but despite numerous visits to the GP, her unusual symptoms baffled doctors.
A coroner was told she went to Royal Sussex County Hospital to get checked out on October 7 last year.
Doctors found Mrs Pinker was suffering from a pulmonary embolism – a blocked blood vessel in the lungs which could be life-threatening if not treated quickly.
Dr Steven Barden, a specialist in pulmonary embolism, said the treatment Mrs Pinker received at the hospital was correct and would have helped to break down the clots which were heading towards her heart.
Mrs Pinker, of Brighton, East Sussex, was then discharged from hospital and reunited with her husband before they headed home.
In shocking evidence, the inquest heard Mr Pinker tell a 999 operator what happened to his wife next.
He was recorded saying: "We just got back (from the hospital) and she has collapsed on the floor, she can't hold her own weight."
Mr Pinker explained how they had been chatting normally in the car on the way to their house and Mrs Pinker had just gone into the kitchen to get a glass of water before going to bed, when she collapsed.
'PEREFCT STORM'
Despite being rushed back to hospital and the valiant efforts of the A&E staff, Mrs Pinker died in the early hours of October 8 last year.
Dr Barden suggested that on the balance of probabilities, another clot was released from Mrs Pinker's pelvis or upper leg just moments before she collapsed.
This clot became lodged in her lungs and despite it's best efforts, her body could not break the clot down before she collapsed.
Mrs Pinker had been the victim of what the coroner described as a "perfect storm" of events.
Her GP, Dr Paul Allen, told the coroner that Mrs Pinker had a family history of deep vein thrombosis (DVT) and yet had been provided with a contraceptive pill which contained oestrogen, an ingredient which can cause the blood to clot.
Senior Coroner Veronica Hamilton-Deeley described Mrs Pinker saying in general she was fit, well and active.
She was a regular runner and somebody who would normally walk for 50 minutes to work each day.
"Most importantly she had a family history of pulmonary embolism and I know that when she was about 17 she was prescribed an oral contraceptive, likely by a family planning clinic. She should not have been."
What is a pumlmonary embolism
Pulmonary embolism is where a blood vessel in the lungs gets blocked – typically caused by a blood clot from a deep vein thrombosis (DVT).
The clot stops the blood flow to the lungs, and in severe cases it can cause immediate cardiac arrest.
Around one in three people with undiagnosed PE don't survive, according to the Mayo Clinic.
However, quick treatment if you do recognise the signs, can greatly reduce the risk of death.
Signs include:
- Breathlessness
- Chest pain
- Coughing up blood
- Fever
- Faster heart rate
- Pain in the leg
According to the National Blood Clot Alliance, while the risk of DVT or PE in adults is 1 in 1000 per year, the equivalent risk in children may be as low as 1 in 1 million per year.
This may be an underestimate, however, because the diagnosis is rarely suspected in children.
The inquest found the prescription of the dual therapy pill Gedarel (corr) which Mrs Pinker was taking was one of a number of contributory factors which created what the coroner dubbed a "perfect storm" leading up to Mrs Pinker's death.
In addition to the pill, Ms Hamilton-Deeley said: "Because of Covid-19 she was working from home and she did not wriggle about unlike many people would."
The coroner concluded this, along with the fact she was running less due to a back problem, significantly limited Mrs Pinker's mobility, a key risk factor in causing blood clots.
In a post-mortem examination, tests revealed Mrs Pinker had a gene mutation which increased her risk of forming blood clots.
MEDICAL HISTORY LOST
However, Dr Barden explained this was only a minimal additional risk factor and not something which would have saved Mrs Pinker's life if it was discovered earlier.
However, in a shocking twist it was revealed that as she moved between GP practices, the details of Mrs Pinker's family history of DVT were lost from her patient records.
The coroner blasted the NHS's record-keeping, adding: "At some stage quite a few years ago and probably several GP practices ago, the family history was not transferred onto the GP electronic records. It should have been.
"This is worrying as quite apart from the devastating effect it has had here, I wonder how many other people are missing their family history off their records?"
However, overall the coroner felt the NHS staff who treated Mrs Pinker did all they could. In an emotional moment, Mrs Pinker's GP Dr Allen apologised to her family for not being able to save her life.
In a narrative verdict, Ms Hamilton-Deeley concluded: "It is death by natural causes. However, there is the anxiety that I have about the fact that this family history was not known about in the first instance.
"Until we can get the records available at the hospital, the hospital will not be aware either. Mrs Pinker died of pulmonary embolism whilst in a pro-thrombotic condition."
In a touching tribute, she told relatives: "She is described as a playful mother. I know that you will keep her memory alive for her children."
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