Told she had gastroenteritis, Adenike (the mother of three young boys aged six, two and one year old) died from what in fact were complications caused by an undiagnosed obstruction of her small bowel. In delivering her narrative verdict, the Coroner noted the failure to diagnose Adenike’s severe abdominal problems and stated:
'Neglect, both medical and nursing, more than minimally contributed to the death on the balance of probabilities.'
Although not forming a part of her narrative conclusion, the Coroner also commented that the death could and should have been prevented.
The family was represented at inquest by Amy Greaves of Shoosmiths. Amy suggests that this case highlighted the importance of listening to patients and checking for signs of sepsis, but the Coroner’s verdict, especially her conclusions of neglect, reflected deeply concerning failures in basic care.
Amy Greaves considers the verdict appropriate and to have been all the family could have hoped for. And while noting that the Trust seems to have learned lessons and promises to improve procedures as a result of Adenike's death, she adds:
‘The mantra of ‘lessons learned’ seems to be repeated after every tragic case of medical harm, and while the measures proposed by the Trust are to be welcomed, those measures should have been in effect in any event since they reflect nothing more than what should be basic care. It should not have taken the death of a young mother for the Trust to implement them.’
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