Source · Prevention of Future Deaths

Gemma Robins

Ref: 2026-0338 Date: 7 Jul 2026 Coroner: Penelope Schofield Area: West Sussex, Brighton and Hove 3 responses identified · 3 indexed addressees View PDF

Response deadline: 10 November 2026 (estimated from the Judiciary.uk publication date).

Date 7 Jul 2026
56-day deadline 10 Nov 2026 est. estimated from the Judiciary.uk publication date
Responses identified 3 of 3

Coroner's concerns

Coroner’s Concerns (source excerpt)
Whilst it is appreciated that communication is difficult when so many different specialist clinicians are involved in a patient’s care particularly when on the Intensive Care Unit. At the time of Gemma’s death clinicians communicated via text, email and telephone to discuss patient care.
View full coroner's concerns
Whilst it is appreciated that communication is difficult when so many different specialist clinicians are involved in a patient’s care particularly when on the Intensive Care Unit. At the time of Gemma’s death clinicians communicated via text, email and telephone to discuss patient care. I heard that these modes of communication can be extremely challenging and prone to miscommunication when multiple teams were involved with a patient. Although some improvements have been made the Court’s Expert witness indicated that these issues will continue to occur unless there is one centralised system/platform which clinicians across both NHS Trusts have access to and facilitates the use real time recording of communications.

Responses

3 respondents

University Hospital Sussex NHS Foundation Trust

PDF
Received

No AI summary available.

University Hospital Sussex NHS Foundation Trust antenatal care

PDF
Received

No AI summary available.

Royal Surrey NHS Foundation Trust

NHS Trust
PDF
Received

No AI summary available.

Report sections

Investigation and inquest
On 08 July 2024 I commenced an investigation into the death of Gemma Louise ROBINS aged 30.  The investigation concluded at the end of the inquest on 06 July 2026. The conclusion of the inquest was that: Gemma died from natural causes however there was a missed opportunity at her antenatal appointment on 23rd April 2024 to investigate possible pre-eclampsia. Blood tests may have revealed abnormal liver function tests which in turn may have led to an earlier admission to hospital. However, it is not possible to say whether this would have prevented Gemma’s death.
Circumstances of the death
On 25th April 2024 Gemma, who was in her third trimester of pregnancy, was admitted to Worthing Hospital following persistent vomiting and an inability to keep food or fluids down since the afternoon 23rd April 2024. She had had an antenatal appointment earlier that day.

On admission on 25th  April 2024 Gemma was acutely unwell and a decision was made for her to have an emergency caesarean.  Her daughter was born at 6:47 hours. Gemma remained unwell following the birth and despite treatment over a period of 40 days on intensive care she did not recover and sadly died on 13th June 2024.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
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Report details

Reference
2026-0338
Date of report
7 July 2026
Coroner
Penelope Schofield
Coroner area
West Sussex, Brighton and Hove

Responses identified

Responses identified 3 of 3
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Nov 2026 (estimated from the Judiciary.uk publication date).

Sent to

Foundation Trust
Chief Executive Royal Surrey NHS Foundation Trust
Chief Executive, University Hospitals Sussex NHS

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