NHS Training is Improved after Inquest Rules Accidental Death

When Martin’s Mother died in hospital, we represented him at the Inquest into her death. As a result of the Inquest there have been significant changes to NHS procedures and training.Martin Leach’s mother died unexpectedly and Martin was sure that something was wrong. He spent 2 months pursuing a complaint against the Queen’s Medical Centre and persuaded the Coroner to hold an Inquest into the death of Mrs Leach. Martin instructed us to represent the family during the Inquest.

Mrs Leach had Crohn’s Disease and she was admitted to the QMC suffering from malnutrition and dehydration. The medical team recommended that she should receive a litre of intravenous fluids over 10 hours. Tragically the infusion pump was incorrectly set. Mrs Leach was given the litre of fluid in less than 1 hour. This overload caused Mrs Leach to suffer heart failure, significantly contributing to her death 2 days later. The original Post Mortem examination concluded that Mrs Leach died from natural causes. However the Coroner, Dr Nigel Chapman, overruled the original verdict and recorded a verdict of accidental death.

There had been previous instances around the country of staff making mistakes because they hadn’t been trained properly in setting up and using medical equipment. Before the Coroner’s Inquest, Mr Leach had already pursued an Independent Review to ensure changes were made nationally to the NHS. As a result of the Review, significant changes were made at the QMC. This included introducing new software to minimise the risk of using incorrect infusion rates. They also improved the staff training and standardised the infusion devices.

If you would like to know more about the ways our Inquests team works with families who have experienced medical negligence, you can contact Emma Zukowska.