A young and healthy woman died from a blood clot in her lung caused by birth control pills after doctors misdiagnosed her with a virus.
Chloe Alicia Ellis, from Dewsbury, had started taking the combined contraceptive pill Yasmin since September 2023, to manage the symptoms of endometriosis.
But in August 2024, the 29-year-old contacted the NHS 111 online service after experiencing sudden chest and back pain and difficulty breathing — claiming she was using the pill.
The online system advised him to go to emergency (A&E) immediately, suggesting through the algorithm that he might have pulmonary embolism, a life-threatening condition.
But she was not informed of this, and staff at Dewsbury Regional Hospital did not have access to the information Chloe had provided online.
Doctors didn't ask about her medications — and misdiagnosed her
According to a coroner's ruling, doctors at the hospital took an incomplete medical history, failed to ask about the contraceptives Chloe was using, diagnosed her with a common virus and sent her home.
Just three days later, Chloe collapsed at home and died at Leeds General Hospital on September 3, 2024.
Statement by Coroner Oliver Longstaff:
“If Chloe had been asked about her contraceptive use on August 31, 2024 in the emergency room, she would have received anticoagulant treatment and been tested for pulmonary embolism.
Based on the evidence, he would have been treated successfully and would not have died three days later."
What is pulmonary embolism?
This is a blood clot that usually forms in the leg and travels to the lungs, where it can block blood flow and be fatal.
A systemic failure: Information provided online did not reach the hospital
According to Judge Longstaff, in theory, data from NHS 111 online could be accessible to emergency hospitals.
But the West Yorkshire Integrated Care Board (ICB) — the body that oversees Dewsbury Hospital — had not enabled this connection.
"Accessing the history from NHS 111 can assist doctors in obtaining complete information and act as a safeguard in the event that the doctor does not obtain an accurate history in the emergency."
The reaction of the authorities
A West Yorkshire ICB spokesman said:
"We are so sorry for the loss of Chloe. Our sincere condolences go out to her loved ones."
"We are analyzing the judge's comments and working with our partners to understand what changes need to be made so that such tragedies do not happen again."
Longstaff has also formally written a report to the ICB “On the Prevention of Future Deaths”.
The risk of birth control pills
The UK Medicines and Healthcare products Regulatory Agency (MHRA) says that combination pills like Yasmin — which contain both estrogen and progestogen — are effective for pregnancy and for treating endometriosis and acne, but:
May increase the risk of blood clots
Estrogen promotes the growth of substances that cause clotting
Can cause stroke if the clot moves
Alarming statistics:
3 million prescriptions for the combined pill were recently given on the NHS
4 million prescriptions for the mini-pill (progestogen-only)
1 in 4 women aged 15–49 uses one of them
About 1% of users are at risk of blood clots
40% of pulmonary embolism victims had symptoms for weeks before death
For every timely diagnosis, there are two more missed that lead to sudden death.
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