Senior Coroner concludes that gross failures amounting to neglect contributed to death of Milo Peart
An inquest touching upon the death of Milo Peart, a 24 year old young man who died at Queen Alexandra Hospital, Portsmouth on 4 July 2020, concluded on Friday 16 June 2023 at Winchester Coroner’s Court.
The Senior Coroner, Mr Christopher Wilkinson, heard evidence from the family and numerous doctors from the Portsmouth Hospitals NHS Trust throughout the hearing, after which he made a finding of gross failures amounting to neglect.
Shoosmiths’ Serious Injury partner Susan Prior and barrister Richard Baker KC of 7BR Chambers represented Milo’s family at the hearing.
Evidence given at the Inquest
Milo had a medical history which included him having required two kidney transplants during his lifetime. On 2 July having had fun in the garden playing football with his brothers, Milo, who was used to ensuring that he kept hydrated, suddenly became incoherent and was exhibiting unusual behaviour.
It was later thought that he may have taken in a large amount of water quite quickly. An ambulance was called and the paramedics were concerned enough to transfer him to the Queen Alexandra Hospital.
When Milo arrived, he remained confused and his speech was erratic. There was concern that he had had a fall and brain scans were obtained due to concerns that he may have suffered a stroke. Milo’s mother raised concerns that he may be suffering from renal problems as she considered that he was exhibiting similar symptoms to those he had suffered after his first transplant, when he had suffered from low sodium (salt). The doctors were also concerned that Milo may be suffering from encephalitis or meningitis and, rightly, also investigated these possibilities.
Blood tests were taken which indicated that Milo’s sodium levels were below his usual levels. The doctors advised that Milo’s CT brain scans showed nothing of concern. Milo was moved to the renal ward because it was decided that there was more likely to be a renal issue involved in Milo’s case, but consideration of a neurological cause was not completely ruled out.
Over the next few hours, Milo became more unwell. He was very confused and erratic and pulled out his cannula. He was distressed and agitated and was running around the ward. A further blood test had showed that his sodium levels had now dropped further but the importance of the results of this test appear to have gone largely unnoticed. His mother was called to try and help calm him and Milo had to be restrained. The medical staff decided to sedate him and he was put back to bed under sedation and wearing restraint mittens. He had been given Hartmann’s fluids to address possible fluid balance problems but there was no monitoring done to assess whether or not this was helping. The low sodium levels were indicating that Milo may be suffering from hyponatraemia, but the doctors failed to include this important possible condition in their differential diagnoses.
Once Milo was sedated, he received no appropriate monitoring for the next 16 hours. The Senior Coroner’s independent medical expert confirmed that Milo should have had his sodium levels checked every four hours, after there had been evidence that his sodium levels had been dropping, and in order to ascertain whether the Hartmann’s fluids had made any positive changes.
During this time, Milo’s sodium levels continued to drop and this had the knock on effect of his fluid balance increasing, resulting in cerebral oedema (fluid on the brain) – something which was evident on the first CT brain scan but which had been inappropriately dismissed as simply showing signs of ‘young brain’.
On 3 June 2020, Milo suffered a complete collapse, resulting in complete cerebral and respiratory arrest. Further scans and tests indicated that he had suffered brain stem death and sadly Milo was formally declared deceased on the morning of 4 July 2020.
The Coroner’s Decision
Mr Wilkinson concluded that there had been numerous missed opportunities to diagnose Milo’s hyponatremia and was concerned about the inconsistencies in note taking, the failure to fully clerk and take a detailed medical history and the failure to escalate Milo to ICU, where he could have undergone effective monitoring and where neuro protective measures could have been implemented.
The Senior Coroner was asked by the family’s legal team to consider whether there could be a legal finding of neglect in this case. In order to make this finding, the coroner would have to be able to conclude that there was a “gross failure to provide basic medical attention to a patient in need and that this failure played a part in their death”.
Mr Wilkinson concluded that there was a total and complete failure to monitor Milo for 16 hours overnight from 2 to 3 of June 2020; there was a failure to make simple checks He decided that this was a gross failure; the trust’s employees had failed to act and these failings had a clear and direct causal link to Milo’s death.
In his narrative, the coroner concluded that Milo Peart had suffered irreversible brain injury due to hyponatremia firstly caused by a fast intake of water and then by lack of appropriate treatment. These gross failures in care, he concluded, amounted to neglect.
Milo’s family said: “We are pleased to finally have answers to the questions that we initially raised almost three years ago. We are grateful to the Senior Coroner, who showed incredible empathy alongside a determination to get to the truth for Milo.
“Nothing can bring Milo back to us and we, his parents and his two brothers, are devastated at his loss. He was a beautiful person, loved my many and who had an amazing future ahead of him. All of that is lost as a result of the failures of this hospital. We hope that there will, at least, be learning from this tragic event so that other families don’t have to go through what we have.”
The coroner has indicated that he is going to investigate matters further to consider whether he will issue a Prevention of Future Deaths report.
Sue Prior, partner at Shoosmiths’ Thames Valley office in Reading said: “The inquest was a distressing experience for Milo’s family (who had already suffered the loss of their child), not helped by the fact that, despite statements and evidence from the trust having been disclosed to the coroner and the family’s legal team a considerable time before the inquest, there were multiple occasions throughout the course of the inquest when the trust’s evidence changed or they provided new, previously undisclosed, information.
“The inquest process is an opportunity for transparency and fact finding. I am pleased that this family now have some answers and hope that it will help them to deal with the sad loss of Milo.”
The family are now considering bringing a clinical negligence claim against the hospital trust.
This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2023