Woman died from contraceptive pill side effect after GP said she just had back pain

Coroner is considering referring the case to the General Medical Council after it raised 'areas of concern' about the conduct of Dr Sunil Simon

Charlotte Foster went to her GP with the symbols of pulmonary embolism but she was diagnosed with mechanical back pain (PA)

A woman died from “untreated side effects” of the contraceptive pill just three weeks after visiting her GP with the symptoms of a blood clot on her lungs, a coroner has ruled.

Charlotte Foster died as suffering a “massive” pulmonary embolism at work on 22 January this year after weeks of complaining about leg and back pain and difficulty breathing.

When she went to her doctor, Dr Sunil Simon, he said she was just suffering from a back problem and advised her to “go for a massage or a spa day”.

The inquest at Shropshire Coroners Court heard Ms Foster’s “only risk factor” was the fact she was taking the combined oral contraceptive pill, Dianette, for around five months before her death.

She have been given the prescription to combat acne in August last year despite telling another doctor she had a family history of pulmonary embolism and breast cancer.

The 23-year-old, from Newport in Shropshire, went to see another GP in October last year and was given a continuing prescription for Dianette, which is now only offered as a treatment for severe acne after other treatments have failed.

The inquest heard a rare but heightened risk of blood clots linked to contraceptive pills had been known about since the 1970s.

Ms Foster’s mother, Cecilia, told the court she had messaged her family on New Year’s Eve to say her ribs hurt and she could not lie down or breathe properly and went to see Dr Simon on 4 January.

Mrs Foster told the inquest Dr Simon did not seem to listen to her daughter when he diagnosed her with “mechanical” back pain.

She also said she was not aware the pill being taken by her daughter posed a higher risk of blood clots than other types.

But Dr Simon, while giving evidence to the hearing, said he had had “no concerns” about the business studies graduate when she came to see him.

“When I observed Miss Foster during that day I did not note any signs of respiratory distress or shortness of breath," he said.

“She did not display any signs of a pulmonary embolism or a deep vein thrombosis.”

Reaching a narrative conclusion, Coroner John Ellery ruled Ms Foster had died from the side-effects of the pill.

"By the 4th of January 2016, on the evidence of family and friends and Charlotte's own texts, Charlotte's condition was increasingly poor and had been for some time fluctuating in severity," he said.

"I accept the evidence of the family and friends and as a fact accept that Charlotte presented on January 4th as Mrs Foster described."

The coroner said he was reviewing whether to refer the case to the General Medical Council as it had raised “areas of concern” over Dr Simon’s conduct.

Additional reporting by PA