Report on the Fatal Pulmonary Embolism Case Linked to Oral Contraceptive Use

Introduction

This report examines the tragic death of Chloe Alicia Ellis, a 29-year-old woman from Dewsbury, who died from a pulmonary embolism caused by a blood clot linked to the use of the combined oral contraceptive pill Yasmin. The case highlights critical issues in healthcare communication and diagnosis, emphasizing the importance of integrating Sustainable Development Goals (SDGs) related to health and well-being, gender equality, and strong institutions.

Case Summary

1. Chloe Alicia Ellis had been taking Yasmin since September 2023 to manage endometriosis.
2. In August 2024, she experienced sudden chest and back pain, breathlessness, and contacted NHS 111 online, informing them about her use of the Pill.
3. The NHS 111 online assessment algorithm identified a likely life-threatening pulmonary embolism and advised her to attend Accident & Emergency (A&E).
4. However, the hospital staff at Dewsbury District Hospital did not have access to the NHS 111 information and misdiagnosed her with a viral illness after taking an inadequate medical history that failed to include her medication use.
5. Three days later, Ms. Ellis collapsed at home and died at Leeds General Infirmary on 3 September 2024.

Findings and Coroner’s Conclusions

• Coroner Oliver Longstaff determined that Ms. Ellis’ life could have been saved if her oral contraceptive use had been considered during her hospital visit.
• Had anticoagulation treatment and diagnostic tests been administered, the pulmonary embolism would likely have been detected and treated effectively.
• The failure to share NHS 111 online assessment data with hospital clinicians was a critical factor in the misdiagnosis.
• The West Yorkshire Integrated Care Board (ICB) had not commissioned access to NHS 111 assessments for emergency departments, limiting clinical information sharing.
• The coroner recommended improving data accessibility between NHS services to prevent future deaths.

Implications for Sustainable Development Goals (SDGs)

SDG 3: Good Health and Well-being

• Ensuring timely and accurate diagnosis of life-threatening conditions like pulmonary embolism is vital to reducing preventable deaths.
• Improving healthcare communication systems aligns with the target to reduce mortality from non-communicable diseases and promote universal health coverage.
• Raising awareness of medication risks and side effects supports informed patient care and safety.

SDG 5: Gender Equality

• Addressing the specific health needs of women, including safe contraceptive use, contributes to gender-sensitive healthcare provision.
• Enhancing education on contraceptive risks and benefits empowers women to make informed health decisions.

SDG 16: Peace, Justice, and Strong Institutions

• Strengthening institutional protocols for information sharing between NHS services promotes accountability and transparency.
• Implementing coroner recommendations supports the development of resilient health systems that prevent avoidable deaths.

Healthcare and Regulatory Context

• The Medicines and Healthcare products Regulatory Agency (MHRA) acknowledges that combined oral contraceptives can increase blood clot risk but states their benefits outweigh risks.
• The risk is linked to oestrogen in the pill, which increases clotting substances in the blood, potentially leading to pulmonary embolism or stroke.
• Approximately 25% of women aged 15 to 49 in the UK use combined or progestogen-only pills, with around 1% at risk of blood clots.
• Known side effects include nausea, breast tenderness, mood swings, headaches, and rare risks of breast and cervical cancer.
• Research indicates many pulmonary embolism deaths are preceded by symptoms that are often missed, underscoring the need for improved diagnostic vigilance.

Recommendations

1. Integrate NHS 111 online assessment data access within hospital emergency departments to ensure comprehensive patient histories.
2. Enhance training for healthcare professionals on the importance of medication history, especially contraceptive use, in diagnosis.
3. Promote patient education on the risks and benefits of contraceptive methods to support informed choices.
4. Strengthen collaboration between healthcare providers and regulatory bodies to monitor and mitigate medication-related risks.
5. Support research and data collection to improve early detection and treatment of pulmonary embolism.

Conclusion

The death of Chloe Alicia Ellis underscores critical gaps in healthcare communication and diagnosis that can lead to preventable fatalities. Addressing these gaps through improved data sharing, professional training, and patient education aligns with the Sustainable Development Goals to ensure healthy lives, promote gender equality, and build strong institutions. Implementing the coroner’s recommendations will be essential in preventing similar tragedies and advancing public health outcomes.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being
   • The article discusses health issues related to blood clots caused by oral contraceptives, misdiagnosis in healthcare settings, and the need for improved medical history taking and communication between health services.
   • It highlights the importance of timely and accurate diagnosis and treatment to prevent premature death.
2. SDG 9: Industry, Innovation and Infrastructure
   • The article mentions the use of NHS 111 online assessment tools and the lack of integration/accessibility of this digital health information between services, pointing to the need for improved healthcare infrastructure and innovation.
3. SDG 16: Peace, Justice and Strong Institutions
   • The coroner’s report and Prevention of Future Deaths report indicate the role of accountability and institutional learning to prevent future medical errors and improve patient safety.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. SDG 3: Good Health and Well-being
   • Target 3.8: Achieve universal health coverage, including access to quality essential healthcare services and access to safe, effective, quality, and affordable essential medicines and vaccines for all.
   • Target 3.4: Reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
   • Target 3.b: Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries and provide access to affordable essential medicines and vaccines.
2. SDG 9: Industry, Innovation and Infrastructure
   • Target 9.c: Significantly increase access to information and communications technology and strive to provide universal and affordable access to the internet in least developed countries by 2020 (implied need for integrated digital health systems).
3. SDG 16: Peace, Justice and Strong Institutions
   • Target 16.6: Develop effective, accountable and transparent institutions at all levels.
   • Target 16.7: Ensure responsive, inclusive, participatory and representative decision-making at all levels.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. For SDG 3 (Good Health and Well-being):
   • Indicator 3.8.1: Coverage of essential health services, which can include access to timely diagnosis and treatment of conditions such as pulmonary embolism.
   • Indicator 3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease, relevant to deaths caused by blood clots and pulmonary embolism.
   • Indicator 3.b.3: Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis, relevant to availability of anticoagulation medication.
2. For SDG 9 (Industry, Innovation and Infrastructure):
   • Indicator 9.c.1: Proportion of population covered by a mobile network, implying the accessibility and integration of digital health tools like NHS 111 online assessments within healthcare infrastructure.
3. For SDG 16 (Peace, Justice and Strong Institutions):
   • Indicator 16.6.2: Proportion of the population satisfied with their last experience of public services, which can reflect trust and accountability in healthcare institutions.
   • Indicator 16.7.2: Proportion of population who believe decision-making is inclusive and responsive, relevant to institutional responsiveness to prevent future deaths.

4. Table: SDGs, Targets and Indicators

Source: dailymail.co.uk