A teenage girl died after being prescribed a powerful contraceptive pill over the phone without her family being told about the drug’s risks, an inquest has heard.
Charlotte Lockwood, 15, of Thetford, died of a pulmonary embolism (EB) on August 17, 2014, eight months after being put on the pill to control heavy menstrual bleeding.
The autistic teenager, who had suffered with period complications since the age of nine, was admitted to West Suffolk Hospital on August 10 after collapsing at home.
She had suffered a cardiac arrest, caused by an EB in an artery leading to her right lung, and died a week later.
In a statement read at Norfolk Corner’s Court on Friday, Charlotte’s mum, Emma Cruickshank, said: “Charlotte was loving and kind, she had a smile that lit up the room, the family she left behind will never be the same again.”
She said Charlotte had been on Cerelle, a progestogen-only pill, prescribed for her menstrual issues but it was ineffective and caused side affects such as weight gain, hair loss and mood swings.
Mrs Cruickshank, who did not attend the hearing due to PTSD, caused by her daughter’s death, said in her statement she had requested a face-to-face appointment at the Grove GP surgery in Thetford in December to have her daughter’s medication changed.
She was called that day by on-call GP Christopher Riddell and they discussed changing Charlotte’s prescription.
As a result, Charlotte was put on Millinette, a combined oral contraceptive which is reported to have a higher risk of causing blood clots.
Mrs Cruickshank said Dr Riddell failed to inform her he was changing the type rather than brand of pill and did not fully explain the risks.
She said: “I firmly believe had Charlotte and I been properly advised about the risk of the combined contraception pill by Dr Riddell the prescription would have been refused because of the deep vein thrombosis and pulmonary embolism in our family history.”
Charlotte’s grandmother and great grandmother had suffered with deep vein thrombosis (DVT).
Dr Riddell told the hearing: “There is no reason I would not have mentioned it (change of drug) it was an important decision to go onto the new medication I would have had done the best I could to inform her (Mrs Cruickshank) about it.”
He said he told Mrs Cruickshank to bring Charlotte in for a check up one or two months after she began taking the new pill – but this had not happened.
The review would have checked her blood pressure, BMI and weight which would have indicated if she should remain on the treatment.
Dr Dennis Cox, an independent expert who reviewed the case, told the court Dr Riddell’s prescription was acceptable under the circumstances and he agreed there were no other suitable options to treat Charlotte’s heavy periods.
Norfolk corner Jacqueline Lake recorded a conclusion of death by natural causes because there was no definitive link to the pill.
She said: “No definitive cause for Charlotte’s catastrophic pulmonary embolism was found, her weight and going on the contraceptive pill and her family history increased the likelihood of clots but it could not be certain this is a direct cause.”
The medical cause of death was listed as severe hypoxic ischemic brain injury caused by a cardiac arrest. Obesity was said to be a contributing factor.
The Grove Surgery has now implemented a number of measures to prevent anything like this happening again.
These include a ban on prescribing new contraception without a face-to-face appointment with a GP, six-month checks with patients on the medication, and only handing patients a three-month trial of any new contraception.
Ms Lake welcomed the changes introduced in the wake of Charlotte’s death.
Speaking after the hearing Sharon Alison, a spokeswoman for the family, said: “They remain resolute that Charlotte was failed on many levels and that had he received the appropriate care and treatment she would be with them today.
“They are encouraged that procedures have changed at the practice which will safeguard patient safety however sadly this is too late for Charlotte.”