Inquest into baby's death neglect verdict
Inquest returns verdict of accidental death contributed to
by neglect following infant’s death in NHS hospital
23rd 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 2nd 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
The family returned to England in January 2009
expecting the NHS to take over Lucas’ treatment which required
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
Doctors at the Homerton were unconvinced that
Lucas was fitting, missing a vital opportunity to make an early
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, 18th 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
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.”