The family of Chloe Ellis, a 29-year-old woman who died from a fatal blood clot in September 2024, is calling for urgent reforms in NHS communication practices. Their appeal follows a critical failure to share vital information about Chloe’s condition between NHS 111 and the A&E department at Dewsbury and District Hospital, which could have helped to prevent her death.
On 31 August 2024, Chloe used the NHS 111 online assessment service after experiencing chest and back pain and breathlessness. Based on her described symptoms and medication history, the 111 algorithm identified a suspected pulmonary embolism, a blood clot blocking the blood supply to her lungs. Though 111 advised Chloe to go straight to a local emergency department, the risk assessment itself was not communicated to Chloe, nor made available to the medics who treated her at Dewsbury and District Hospital.
Chloe was misdiagnosed with a respiratory infection and discharged from hospital. Three days later, Chloe collapsed at the home she shared with husband, Dan Ellis. In spite of the efforts by medical staff to treat Chloe, she died later that day at Leeds General Infirmary.
Chloe’s case has received extensive media coverage including in broadcasts by ITV News and BBC Look North – where Stewarts partner Frank Pinch commented on the failures resulting from lack of information sharing by NHS bodies – as well as The Mirror and Manchester Evening News.
The importance of information sharing
At Chloe’s inquest, held at Wakefield Coroner’s Court on 9 June 2025, Coroner Oliver Longstaff concluded that failure to obtain Chloe’s full medical history at A&E, combined with the inaccessibility of her 111 online assessment, likely cost Chloe her life.
The Coroner concluded that had staff known about the medication she was taking, Chloe should have been diagnosed with a pulmonary embolism, and would have received life-saving treatment. He went on to issue a Prevention of Future Deaths Report to West Yorkshire Integrated Care Board (ICB). The report stated that outcomes of NHS 111 online assessments should be made accessible to emergency department clinicians.
Throughout the UK, practice varies as to whether NHS 111 assessments are shared with A&E departments. West Yorkshire Integrated Care Board has not previously commissioned accessibility to NHS 111 online assessments for local hospitals. Chloe’s family are now campaigning for report sharing to become standard practice, as it could save lives.
Chloe’s mother, Jean Walker, says: “Chloe did everything right. She sought help and gave accurate information to the NHS 111 call handler. 111 identified a condition that can be fatal if left untreated, yet that information wasn’t shared with anyone, not even Chloe. So not only was this assessment not passed on to clinicians at A&E, even Chloe wasn’t able to communicate this herself. Had this vital information been shared, she would have received treatment that would have undoubtedly saved her life.”
Call for government action
Chloe’s story sheds light on a broader issue within the NHS: that services like 111, A&E and GP practices often operate with limited visibility of each other’s assessments and interactions with patients.
Amy Fielding, partner in Stewarts’ Medical Negligence team and a former nurse, has been working with Chloe’s family to raise awareness of this problem and urge the government to implement much needed changes consistently across the NHS.
Amy comments: “The current system needs to change quickly. If a suspected diagnosis can be passed directly to A&E, this would save an already overstretched emergency service significant time and resources. Patients assume that their records follow them, when that simply isn’t the case. Part of the problem is that A&E does not fall under the same ‘arm’ of the NHS as 111 and therefore relies on regional care boards to expressly implement a system of information sharing.”
As part of the Labour government’s 10-year NHS plan, it has promised to transform the NHS app into “a world-leading tool for patient access, empowerment and care planning,” with the aim to act as “a doctor in your pocket.”
“The government’s 10-year plan for the NHS should also include action to ensure interoperability and communication across all NHS urgent care services,” Amy says.
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