A healthy young woman died from a blood clot to the lungs caused by the Pill, after medics misdiagnosed her with a virus.
Chloe Alicia Ellis, from Dewsbury, had taken the combined oral contraceptive pill Yasmin to manage her endometriosis since September 2023.
But in August 2024, the 29-year-old contacted NHS 111 online after suddenly experiencing chest and back pain, as well as breathlessness and informed them she was on the Pill.
The online assessment urged her to attend A&E having concluded via the algorithm that she was likely suffering from a potentially life-threatening pulmonary embolism.
Yet, it did not her inform her of this and staff at Dewsbury District Hospital did not have access to the information given to NHS 111.
Now, a coroner has found doctors at the hospital took an ‘inadequate’ medical history from Ms Ellis, failing to ask about her medication history—specifically her use of oral contraception—and she was diagnosed with a viral illness before being discharged.
Just three days later she collapsed at home and died at Leeds General Infirmary on September 3, 2024.
At the inquest into Ms Ellis’ death, coroner Oliver Longstaff determined that her life could have been saved if information she gave to the NHS 111 service had been passed to the hospital.
Chloe Alicia Ellis, from Dewsbury, had taken the combined oral contraceptive pill Yasmin (pictured) to manage her endometriosis since September 2023
The NHS 111 online assessment urged her to attend A&E having concluded via the algorithm that she was likely suffering from a potentially life-threatening pulmonary embolism. Yet, it did not her inform her of this and staff at Dewsbury District Hospital did not have access to the information given to NHS 111
He said: ‘Had a history of her oral contraceptive use been obtained when Chloe attended a local hospital emergency department on 31 August 2024, she would have been given anticoagulation medication and undergone tests that would have revealed the pulmonary embolism.
‘She would have received effective treatment for the pulmonary embolism and, on the balance of probabilities, would not have died three days later.’
The condition occurs when a clot forms in a vein, usually in the leg, before traveling to the lung where it gets stuck.
Such blockages can prove fatal if the clot blocks the blood supply to the lungs.
According to the coroner, it is possible for NHS 111 online assessments to be made accessible to A&E, but the West Yorkshire Integrated Care Board (ICB)—which oversees Dewsbury District Hospital—had not commissioned accessibility to NHS 111.
Mr Longstaff said: ‘The availability of NHS 111 online assessments to clinicians in emergency departments may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in emergency departments.’
A spokesperson for West Yorkshire ICB said the trust was working to understand what changes were needed going forward.
They said: ‘We are very sorry to hear about what happened to Chloe, and our sincere condolences go to her loved ones.
The NHS says natural family planning can be up to 99 per cent effective when done correctly and around 75 per cent if not used according to instructions. By comparison, the Pill, implant, IUS and IUD are 99 per cent effective with perfect use, while condoms are 98 per cent
Just three days after contacting NHS 111 she collapsed at home and died at Leeds General Infirmary on September 3, 2024
‘We have been reviewing the points raised by the coroner and we are working with all our relevant partners to understand the learning and the current arrangements to establish what changes are required in order to prevent similar losses in future.’
Mr Longstaff has also written to the ICB with his findings in a Prevention of Future Deaths report.
The Medicines and Healthcare products Regulatory Agency (MHRA) — which polices the safety of drugs used in Britain — notes the combined Pill, which is also often taken as an endometriosis and acne medication, can increase the risk of blood clots.
However, its ‘benefits far outweigh the risk of serious side effects’, it adds.
The reaction is believed to be due to how oestrogen—a hormone in the combined pill—boosts the number of clotting substances in women’s blood. The Pill contains oestrogen and progestogen.
At higher levels, this raises the risk of a clot forming anywhere in the body, such as the lungs. If this becomes dislodged it can also travel to the brain—triggering a stroke.
Latest NHS figures for suggest there were almost 3million prescriptions for the combined pill and more than 4million for the mini pill, which just contains progestogen.
Around a quarter of all women aged 15 to 49 are on either the combined or progesterone only pill.
The proportion of women taking oral contraceptives has fallen by more than two-thirds, from 420,600 in 2012/13 to 126,400 in 2022/23, according to the NHS data. Around 555,400 women turned to the health service’s sexual and reproductive health services in 2022/23—equivalent to four per cent of 13 to 54-year-olds
But the Faculty of Sexual & Reproductive Healthcare estimates around 1 per cent of women using the contraceptive are at risk of suffering blood clots.
Known side effects of the drug—proven to be over 99 per cent effective at stopping pregnancy—also include nausea, breast tenderness, mood swings and headaches.
Rarer complications of the combined and the mini pill, however, can include a slightly heightened risk of breast and cervical cancer.
Research also suggests 40 per cent of patients who die from a pulmonary embolism complained of nagging symptoms for weeks before their death.
For every pulmonary embolism diagnosed in time, there are at least another two where the diagnosis was missed and resulted in sudden death, according to the charity Thrombosis UK.
