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The ‘extremely cut’ teenager sent home from hospital died a day later

A girl collapsed and died a day after being discharged from hospital without a formal diagnosis and no prescribed treatment, a coroner has heard.

Lilly Proctor, 13, was taken to the Emergency Department at Pinderfields Hospital in Wakefield with complaints of breathing difficulties and chest pains. Of the five doctors who saw Lilly before she died, only one of them knew about the family history of blood clots. Lilly was said to have a strong family history of thromboembolic disease (a condition in which clots form in the deep veins).




Doctors variously believed her symptoms in hospital were cardiac in origin, to anxiety, or caused by an infection or due to pneumonia, an inquest heard.

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Lilly died on 3 April 2022 at Pinderfields Hospital after collapsing at home. A post mortem examination gave her cause of death as 1a, massive pulmonary thromboembolism, 1b, deep vein thrombosis and 1c, pathogenic PROS variant 1 (a genetic disorder).

Post mortem findings were consistent with Lilly having developed a series of non-fatal pulmonary thromboembolisms (blood clots in the lungs) before her final collapse.

An inquest into her death heard from an independent expert paediatrician, who said features on an electrocardiogram (heart test) that doctors thought were attributable to Lilly’s age were potentially indicative of a number of conditions, such as a heart strain and pulmonary embolus.

West Yorkshire Coroner Oliver Longstaff, in a report into preventing future deaths, wrote: “Lilly was discharged from hospital on 2 April 2022 without a formal diagnosis and no prescribed treatment. She failed to complete an exercise test asking her to walk a short distance around the ward, although her heart rate (which remained above 100 bpm throughout her admission) was recorded as the same at the start and end the test.”