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Bosses at Royal Preston Hospital have been ordered to make changes after a coroner ruled a woman’s death was caused by neglect.
Marina Young died in June 2022 after a 39 hour wait for a hospital bed at the A&E department and senior coroner Dr James Adeley concluded her death, due to asthma, was preventable. The neglect, he ruled, involved both a “gross failure to provide appropriate assessment and medical care and an inadequate escalation of her management to specialist physicians or ITU”.
He has now issued a Prevention of Future Deaths report which legally compels hospital bosses to make changes to prevent further incidents. This, he said, was necessary due to the lack of action taken by Lancashire Teaching Hospitals Trust in the two years since Marina’s death.
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Marina, from Ribbleton, had spina bifida, which limited her mobility, lthough she lived independently, could walk short distances, and would see her family every day.
She was the first baby in the UK to have a bladder transplant and had to use daily catheters to empty her bladder due to the impact of her spina bifida.
Marina was diagnosed with asthma as a child, but this was well controlled up until the severe episode that led to her being taken to the hospital.
She was driven to hospital at 7pm by her sister Michelle Young, who is a retired hospital. Although unable to stay due to Covid restrictions, Michelle gave a full hand over of her medical history, including her continence needs and her reliance on catheters and stayed in regular contact with Marina via text message.
The following evening, Marina texted Michelle to say she had been told she might need to be moved to intensive care and the next morning Michelle returned to the A&E department to drop items off for Marina, only to be told that she had died.
When Michelle went to see Marina, she found that she still had her clothes and shoes -which she could remove without assistance – on and smelt strongly of urine.
It was later found that during her 39 hour stay, none of the six nurses who saw Marina assessed her toilet needs or assessed what sensory impacts would be caused by her spina bifida as she spent the entire time seated in a chair.
An internal investigation by the Royal Preston Hospital had already identified numerous failures in the treatment of Marina’s asthma attack and now faces additional pressure to prove it can change.
Speaking after the inquest ruling, Michelle said: “I feel Marina’s voice has been heard and that it has been recognised that her life did matter. Our dad never recovered from Marina’s death and did not live to see the coroner’s ruling but he would have been relieved to know that justice has been done.
“All we have ever wanted is to protect other patients and even saving one life would make the pain we have been through worthwhile. That’s what Marina and my dad would have wanted and it brings me closure to know that has been achieved.”
A Lancashire Teaching Hospitals spokesperson said: “The Trust would like to offer its sincere condolences to the family and friends of Marina Young and apologise for the failings identified in our own investigation and the Coroner’s report.
“We welcome the independent scrutiny of the Coroner and are committed to the further actions and learning identified in the inquest.”
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