Chesterfield Royal Hospital NHS Foundation Trust

Health and care · NHS trust

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First report 19 Mar 2016•Latest report 26 May 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
2

Described in responses

Concerns and recipient responses

Statements from Chesterfield Royal Hospital NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Jessica Hodgkinson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jessica Hodgkinson died on 14 May 2021 at Chesterfield Royal Hospital shortly after giving birth, following a pulmonary embolism arising from a deep vein thrombosis and acute anaphylaxis of unknown cause. The inquest identified failures to communicate and follow up the plan for prophylactic tinzaparin until birth, and concerns about consideration and documentation of her Klippel-Trenaunay Syndrome during pregnancy.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chesterfield Royal Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of follow-up communication about care provided during inter-provider transfer

    Wider context from the report

    “(3) I heard evidence that following Jess’ discharge from Sheffield on 26 April 2021, Chesterfield did not receive any communications from Sheffield about Jess’ care during her time in Sheffield. I am concerned that there was no process in place in Chesterfield to follow up and find out what had happened during Jess’ short period under the care of Sheffield. Had efforts been made to liaise with the team in Sheffield, the tinzaparin issue might have been identified. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chesterfield Royal Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate handover of treatment plans during transfer of care

    Wider context from the report

    “(2) I heard evidence that there was no communication to the team in Sheffield that Jess’ consultant in Chesterfield intended that she should continue to receive tinzaparin until birth. Therefore, when Jess was discharged from Sheffield on 26 April 2021, she was not given tinzaparin because the team in Sheffield were unaware of this plan. I am concerned, therefore, about the quality and adequacy of the information handed over to Sheffield at the point of Jess being transferred into their care. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chesterfield Royal Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess and document the potential impact of KTS on pregnancy

    Wider context from the report

    “(4) I heard in evidence that some staff were unaware of KTS and its potential implications for pregnancy. This was understandable. However, I did not see evidence of any consultant having properly considered and then documented in Jess’ notes the potential impact that KTS might have had on Jess’ pregnancy. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chesterfield Royal Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify non-receipt of prescribed tinzaparin during transfer of care

    Wider context from the report

    “(1) I heard evidence from Jess’ consultant that she intended that tinzaparin would be taken by Jess up until birth. When Jess was discharged from Sheffield back into the care of Chesterfield, nobody in Chesterfield identified that Jess was not receiving the tinzaparin which the consultant told the inquest ought to have been in place until birth. ”
    Open source report

  2. Derbyshire

    AI-generated summary

    Ann Catherine Jacobs · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ann Catherine Jacobs was found unresponsive and in asystole in hospital at approximately 3.00am on 25 February 2014, after being treated for severe hypokalaemia. The report identified concerns that potassium monitoring was not carried out every eight hours in accordance with hospital guidance, and that no further blood test was taken after 06.38 on 24 February.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chesterfield Royal Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor potassium levels every 8 hours in severe hypokalaemia

    Wider context from the report

    “That when a diagnosis of severe hypokalaemia is made in patients that there is the monitoring of potassium levels every 8 hours and adherence to the Trust Management of acute hypokalaemia guidance. This is particularly important as the guidance itself makes clear “ECG changes can occur at any level of hypokalaemia. Hypokalaemia can result in flat T waves, ST depression, QT interval prolongation and prominent U waves. Ventricular arrhythmias (eg torsades de pointes, ventricular tachycardia and ventricular fibrillation) can also occur. It is of concern that this monitoring did not take place during the last admission of Ann Jacobs and by way of treatment for her identified severe hypokalaemia. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026