A senior coroner has warned of “confused lines of communication” within the NHS following the death of a 30-year-old mother who was treated by the trust managing St Richard’s Hospital.
Gemma Robins died on 13 June 2024, approximately 40 days after giving birth. An inquest into her death, which concluded on 6 July 2026 at Horsham Coroner’s Court, identified missed diagnostic opportunities and systemic failures in how different NHS trusts coordinated her care.
The Senior Coroner for West Sussex, Penelope Schofield, subsequently issued a Prevention of Future Deaths report to University Hospitals Sussex NHS Foundation Trust and Royal Surrey NHS Foundation Trust. University Hospitals Sussex is the body responsible for maternity and intensive care services at St Richard’s Hospital in Chichester and Worthing Hospital.
Missed opportunities in care
The inquest heard that Ms Robins died from natural causes involving multi-organ failure, acute necrotising pancreatitis, and Acute Fatty Liver of Pregnancy (AFLP).
Coroner Schofield identified a specific missed opportunity to investigate potential pre-eclampsia during an antenatal appointment on 23 April 2024. At this 36-week check-up, Ms Robins’ high blood pressure was not re-checked, and a required urine test was not performed.
Medical evidence suggested that while earlier intervention might have altered the course of her treatment, the coroner could not definitively state that it would have prevented her death. However, the breakdown in communication during her subsequent decline was highlighted as a critical area of concern.
“Confused lines of communication”
As Ms Robins’ condition deteriorated, clinicians at University Hospitals Sussex attempted to arrange a transfer to a specialist hepatobiliary (HPB) unit at the Royal Surrey NHS Foundation Trust.
The inquest was told of significant difficulties during this process. One consultant attempting to arrange the transfer was unable to get through to the specialist unit via telephone. The coroner’s report described “confused lines of communication” between the two trusts, which led to delays in securing specialist advice and coordinating the transfer of a critically ill patient.
The official Prevention of Future Deaths report noted that these communication barriers created a risk that other patients could face similar delays in life-critical situations.
Safety changes at Sussex hospitals
In response to the coroner’s findings, University Hospitals Sussex has implemented several safety measures and updated its clinical protocols. These changes affect maternity and intensive care services across the trust’s sites, including Chichester.
