Wakefield: Coroner orders new blood clot tests after teen’s death

A coroner has called for new screening tests to detect blood clots in children after the death of a 13-year-old girl.

Lilly Proctor died on 3 April 2022 at Pinderfields Hospital, Wakefield, after collapsing at home earlier.

She had previously been admitted to hospital on April 1 with shortness of breath and chest pains.

Coroner Oliver Longstaff said she had been discharged from hospital “with no formal diagnosis and no prescribed treatment” before her death.

He said more action would be needed with other cases to “prevent future deaths” after recording a narrative conclusion following the inquest into Lilly’s death in April 2024.

Mr Longstaff said his concerns were that there was no specific screening tool for children available in the UK and the National Institute for Health and Care Excellence (NICE) guidelines for these types of cases were specific to adults only and did not apply to children .

He also cited a lack of resources to treat a circulating blood clot, known as a thromboembolism, means “doctors working with children can be at a disadvantage in diagnosing and treating the condition”.

He was also concerned that Lilly’s family had a strong family history of thromboembolic disease, but only one of the five doctors who saw her at the hospital noted her mother’s past experience with blood clots from an inherited condition.

Mr Longstaff added in his report that “it cannot be said on the balance of probabilities that any step taken as an alternative to discharging Lilly on 2 April 2022 would have prevented the tragedy of her terminal collapsing the next day”.

A joint pediatric and forensic post mortem examination indicated the cause of her death as a massive pulmonary thromboembolism, deep vein thrombosis and a genetic mutation that affected blood clotting.

Mr Longstaff’s report into preventing future deaths ended with him asking NICE and the Royal College of Paediatrics and Child Health (RCPCH) to respond to his findings within 56 days with details of “action taken or proposed to be taken”.