A senior coroner has issued a critical warning to pregnant women regarding the use of a specific medication prescribed for migraines, following the tragic death of a newborn baby. The case highlights significant concerns over clinical guidance and prescription safety protocols within the NHS.
Tragic Outcome in Sunderland
Baby Avery Jake Hall passed away in Sunderland on the 13th of November 2024, at just four days old. A post-mortem examination revealed the infant suffered from severe lung damage, critically low oxygen levels, and significantly reduced blood flow. These conditions are known complications associated with the use of the prescription drug Candesartan during pregnancy, particularly when administered in the second and third trimesters.
Compromised Development and Prescription History
Avery's development in the womb was severely compromised due to reduced amniotic fluid, which led to poor lung formation and impaired kidney function, affecting urine production. His mother had been prescribed Candesartan, a medication that works by relaxing blood vessels, to manage her recurring migraines before she became pregnant. The prescription was initiated by her GP shortly before her 22nd birthday, set as a daily 4mg dose on a repeat prescription of 28 tablets.
Critically, at the time of this initial prescription, no advice was provided regarding the potential risks the drug posed if she were to conceive. This omission occurred despite existing National Institute for Health and Care Excellence (NICE) guidance explicitly warning against the medication's harmful effects on fetal development.
"Unclear and Indecisive" Advice During Pregnancy
When Avery's mother discovered she was pregnant in April 2024, she proactively contacted her GP to inquire about the safety of her prescribed medications. During a telephone consultation, she received specific advice to avoid three out of her six prescriptions. However, the coroner's report states she was not given explicit, clear instructions to discontinue the use of Candesartan.
As a result, a repeat prescription for Candesartan was issued and continued to be approved by the system until merely 12 days before Avery's birth. The mother, who continued to suffer from migraines throughout her pregnancy, remained unaware of the grave dangers associated with taking the medication during this critical period.
Coroner's Findings and Systemic Failures
David Place, the Senior Coroner for the City of Sunderland, published a Prevention of Future Deaths report on Monday. He concluded that Avery's death was directly caused by complications known to arise from Candesartan use in pregnancy and stated unequivocally that "action should have been taken" to prevent it.
"His mother had continued to use this medication which had been prescribed to her since 2022 being unaware of the risks it posed due to a combination of unclear and indecisive advice at the outset and no additional advice about the safety of the medication from clinicians involved in her antenatal care," Mr Place stated.
The coroner identified a systemic failure in the prescription approval process. "Despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription," he said. "There were no warnings placed on the system which would have alerted the clinician approving the request for the repeat prescription that the patient was pregnant thus necessitating a review."
Broader Context of Maternity Care Scrutiny
This distressing case emerges amidst heightened scrutiny of maternity services across England. It has been reported that 14 NHS trusts are currently facing a national investigation into the standards of their maternity care, underscoring a pressing need for improved safety protocols and clearer communication between healthcare providers and patients.
The coroner's report serves as a solemn reminder of the paramount importance of explicit, unambiguous medical advice for pregnant women regarding all medications. It also calls into question the efficacy of electronic prescription systems in flagging critical patient information, such as pregnancy status, to prevent similar tragedies. NHS England has been approached for comment on the findings of this report.
