Hodge Jones & Allen

Inquest returns verdict of accidental death contributed to by neglect following infant’s death in NHS hospital

 

23^rd June 2010

 

The Coroner today returned a verdict of accidental death contributed to by neglect at Poplar Coroners Court in relation to the tragic death of Lucas Stachursky aged 7 months on Sunday, 17 May 2009 at Homerton University Hospital.  The Coroner concluded that Lucas died as a result of an accidental overdose of Phenytoin (an anti-convulsant medication), contributed to by neglect and natural disease, and that the failures in his care amounted to a gross lack of medical attention, which directly contributed to Lucas’s death.

 

Lucas was born on 2^nd October 2008 with Sturge-Weber Syndrome (SWS), a rare brain abnormality. Whilst in Italy with his parents in December 2008 he developed signs of epilepsy and his condition was correctly diagnosed by Italian doctors.

 

The family returned to England in January 2009 expecting the NHS to take over Lucas’ treatment which required specialist help.

 

Unfortunately, the NHS failed miserably to organise his care and almost every contact they had with the NHS was mismanaged, from their son's referral to a specialist unit at Great Ormond Street Hospital to the very last minutes of his life.  Loss of letters of referral and other delays meant that Lucas was not seen by the doctors of the Sturge-Weber Clinic until 12 May 2009.

Three days later, on the evening of Friday May 15th Lucas started vomiting and his parents suspected he was undergoing epileptic seizures. They dialled 999 and he was taken to Homerton Hospital A&E.

 

Doctors at the Homerton were unconvinced that Lucas was fitting, missing a vital opportunity to make an early diagnosis.

 

A junior doctor, under the apparent direction of a Consultant, prescribed the drug Phenytoin but failed to understand the prescribing direction and instituted a continuous infusion, thereby prescribing a massive overdose which killed Lucas.  This doctor’s error was not recognised by a multitude of nursing and medical staff for over four hours.

 

Lucas Stachursky died at about 2:00 a.m. on Sunday, 17 May 2009.

 

The hospital trust admitted that Lucas’ death was the result of this overdose which was caused by negligent treatment, in a letter dated Friday, 18^th June 2010, one working day before the inquest.

 

The inquest heard evidence over 3 days.

 

The verdict confirmed that the care provided by Homerton University Hospital was grossly lacking, and the gross lack of clinical management contributed to Lucas’s death.  Wider issues regarding a national problem with suboptimal prescribing by Junior Doctors were raised, and the Coroner is to report this to the National Patient Safety Agency. They will be obliged to respond with their views.  It is hoped that more stringent monitoring and assessment of Doctor’s prescribing abilities can be achieved.

 

Lucas’s parents, Anna Holzscheiter, 33, and Ben Stachursky, 32, have returned to their native Germany but came back to England for the inquest. They said:

 

“The sudden death of our son Lucas in May 2009 at Homerton University Hospital has been the most devastating event of our lives, one that we had never imagined would happen to us. Despite Lucas’s complex congenital medical condition, we saw a happy and thriving boy every day, who was developing very well and for whom we had so many hopes and wishes.

 

“Only within the last few days, when we were finally able to see all the evidence gathered to establish the cause of Lucas’s death, did we realise the magnitude and extent of incompetence, carelessness, breech of duty and mismanagement by NHS medical staff that, ultimately, resulted in the death of our child. We cannot express our despair and anger concerning the fact that those whom we entrusted with our child due to their seeming knowledge and competence have failed Lucas so gravely.

 

“We will do everything we can to ensure that the series of major and minor medical mistakes that took our son away from us so unexpectedly will be investigated to the fullest extent possible. Apart from what has been determined in this hearing today, we will seek to exhaust all remedies to make sure that those responsible for these grave mistakes will be held accountable for their actions and inactions with the most severe consequences possible – and to ensure that all necessary measures will be taken to avoid that such tragic incidents can occur in the future.

 

A claim for compensation is being pursued with the help of their solicitors, Hodge Jones & Allen LLP.

 

This inquest was an “Article 2” inquest which involved a broader examination of the issues than a conventional inquest. This is because it is alleged that the case involves a breach of Article 2 of the European Convention on Human Rights, the ‘right to life’.

 

Patrick Allen, solicitor at Hodge Jones & Allen LLP representing the family said: “The Human Rights Act 1998 assisted my clients in the investigation into what went wrong in this case. There appears to have been a system failure in the NHS causing Lucas’ death and a breach of Article 2 of the ECHR.

 

"As a result, the state has a duty to carry out a full inquiry into the circumstances and this was done by a full Article 2 compliant inquest at Poplar Coroners Court. The inquest has provided some answers to the many painful questions raised by this tragic case.”

 

Dawn Treloar, solicitor at Hodge Jones & Allen LLP for the family said: “We hope that changes will now be made to ensure that doctors cannot reach a senior level of their training without formal checks being undertaken on their prescribing abilities and competence. Had systems been in place to do this then this fatal error may not have happened.”