Coroner calls for new blood clot tests after teenage girl'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 in Pinderfields Hospital, Wakefield, after collapsing at home.

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

Yorkshire West Eastern Coroner, Oliver Longstaff, said she had been discharged from hospital "with no formal diagnosis and no prescribed treatment" before her death.

He said that with other cases more action would be needed to "prevent future deaths" after he recorded a narrative conclusion following an inquest into Lilly Proctor’s death earlier this year.

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

He added that a lack of resources to treat a circulating blood clot, known as a thromboembolism, meant "clinicians working with children may be disadvantaged in diagnosing and treating the condition."

He was also concerned that Lilly's family had a strong history of thromboembolic disease, but only one of the five doctors who saw her at hospital picked up on her mother's experience of blood clots due to an inherited condition.

In his Prevention of Future Deaths (PFD) report, the coroner added 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 collapse the following day."

A joint paediatric and forensic postmortem examination gave the cause of her death as a massive pulmonary thromboembolism, deep vein thrombosis, and having a genetic mutation that affected blood clotting.

Mr Longstaff's Prevention of Future Deaths report, urged NICE and the Royal College of Paediatrics and Child Health (RCPCH) to respond to his findings.