A coroner has raised concerns about communication between hospitals following the death of Gemma Robins, a new mother who died 40 days after giving birth in 2024. During an inquest into her death, it was found that a key opportunity to detect possible pre-eclampsia—a serious condition during pregnancy that can cause high blood pressure and organ damage—was missed during an antenatal appointment in April 2024. Blood tests at that time might have revealed abnormal liver function, which could have led to an earlier hospital admission. Two days after the appointment, Robins was admitted to Worthing Hospital due to persistent vomiting, and her baby was delivered by Caesarean section. She was then transferred to the intensive care unit at Royal Sussex Hospital in Brighton, where she later developed internal bleeding. Robins was transferred to the Royal Surrey County Hospital in Guildford for a procedure to stop the internal bleeding. She underwent emergency surgery, but doctors later concluded there were no further surgical options available. She passed away on June 13, 2024, due to a severe liver condition and inflammation of the pancreas. The coroner, Penelope Schofield, highlighted confusion and unclear communication between medical staff at the Royal Surrey NHS Foundation Trust and University Hospitals Sussex NHS Foundation Trust. She noted that communication between the hospitals occurred primarily through text, email, and telephone, which can lead to misunderstandings when multiple teams are involved. A report aimed at preventing future deaths addressed to University Hospitals Sussex NHS Foundation Trust found that there were not enough safeguards in place to ensure basic checks during antenatal appointments. Robins’ family described her as loyal, caring, and full of humor, with a deep love for animals, music, and fashion. They expressed confidence that she would have been an incredible mother. While the family welcomed the coroner’s decision to issue the prevention of future deaths report, they emphasized the need for better antenatal investigations and timely recognition and treatment of acute fatty liver of pregnancy, a rare but serious condition that can occur during pregnancy. Meg George, a solicitor representing Robins' family, stated that the coroner acknowledged missed opportunities to investigate possible pre-eclampsia before Robins’ death. The family remains concerned about the maternity care she received. Dr. Bill Jewsbury, medical director at Royal Surrey NHS Foundation Trust, expressed condolences and acknowledged the communication challenges between the hospitals. He stated that the Trust is committed to improving communication through a new and more robust system. University Hospitals Sussex NHS Foundation Trust has been asked for a response.