A little boy died at just four days old – and a coroner has blamed the advice his mum was given about the medication she could take while pregnant
City Hall in Sunderland(Image: Sunderland City Council)
A coroner has raised concerns after a baby died at just four days old after pregnancy complications believed to be related to a migraine medication his mum had been taking. Avery Jake Hall was born on November 9 2024 – and died just days later on November 13.
At an inquest into his death in Sunderland, coroner David Place found he had died due to complications from the use of a drug called Candesartan during pregnancy. The coroner has now also issued a formal “prevention of future deaths” report to the GPs’ practise the family used, as he said there was concerns about the advice that the baby’s mum was given about her medication.
The little boy’s mum was a patient at the Riverview Surgery GPs practice in Sunderland city centre. The coroner said that during the inquest – which concluded on January 23 this year – he had heard evidence that he found concerning.
Mr Place, the senior coroner for Sunderland, concluded at the inquest: “Avery Jake Hall died from complications known to arise when candesartan is used throughout pregnancy particularly in the second and third trimester and 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.”
He added that Avery Jake’s “development in pregnancy had been compromised by reduced amniotic fluid leading to poorlung development and impairment of urine production by the kidneys”. The coroner said that the baby’s mum had continued to take the drug and added: “She did not receive definitive advice from clinicians to stop taking it despite various opportunities to do so.”
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A coroner has the power to raise concerns where they believe action can be taken to prevent a similar death occurring. In this case, Mr Place has written to Riverview Surgery and they Royal College of GPs to raise the issue.
He said that even though the baby’s mother had “sought advice from her GP about which of her prescribed medications were safe to use during pregnancy”, she was not told to avoid taking Candesartan. The coroner added: “During the telephone consultation with her GP on 11th April 2024 she was given specific advice to avoid using 3 of 6 prescriptions.
“I am concerned that the evidence highlighted that Avery’s mother was given only generic advice that it was best to avoid all medication during pregnancy but was not given specific advice to stop using Candesartan, and the risk of continuing to take this medication in pregnancy was not identified during this consultation.”
The coroner said that she was not told of the risks of the medication when she was first prescribed it, either, and nor did any meetings with clinicians in the run-up to the baby’s birth identify that this could be a problem. Mr Place added: “Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk.
“I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review.
“The last repeat prescription being approved only 12 days prior to Avery’s birth. I am concerned that despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription and, in addition to that, 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.”
Riverview Surgery has not responded to ChronicleLive’s request for comment.
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