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| Version 1 | Version 2 |
|---|---|
| Woman's death was 'gross failure' | Woman's death was 'gross failure' |
| (about 1 hour later) | |
| Gross failures and neglect contributed to the death of a grandmother-of-five after a routine procedure went wrong at a Birmingham hospital, a coroner ruled. | Gross failures and neglect contributed to the death of a grandmother-of-five after a routine procedure went wrong at a Birmingham hospital, a coroner ruled. |
| Rosemary McFarlane, 64, died after being given a chemical that was 10 times the recommended concentration, which burned her lungs and killed her. | Rosemary McFarlane, 64, died after being given a chemical that was 10 times the recommended concentration, which burned her lungs and killed her. |
| She was the only patient to be given a phosphate-buffered saline solution at Heartlands Hospital last year. | |
| The coroner recorded a narrative verdict at Birmingham Coroner's Court. | The coroner recorded a narrative verdict at Birmingham Coroner's Court. |
| Mrs McFarlane had a lung condition that affected her breathing and needed a routine test called a bronchoscopy to check her lungs, the inquest heard. | Mrs McFarlane had a lung condition that affected her breathing and needed a routine test called a bronchoscopy to check her lungs, the inquest heard. |
| 'Terrible mistake' | 'Terrible mistake' |
| To perform the test she was given a phosphate solution, but due to the high concentration it was highly acidic and burnt her lungs. | To perform the test she was given a phosphate solution, but due to the high concentration it was highly acidic and burnt her lungs. |
| The inquest heard that medical staff failed to notice a "10x" label on the bottle, which referred to the concentration of the solution they took to be a single concentration. | |
| Pathologist Adrian Moorfield said this was the "pivotal moment which led to her suffering from blood clots and pneumonia leading to her death on 22 August 2008, 10 days after she was given the chemical. | |
| " | |
| It's important the lessons are shared with other trusts so that no other family has to go through what the McFarlane's have Family solicitor Guy Forster | |
| which led to her suffering from blood clots and pneumonia leading to her death on 22 August 2008, 10 days after she was given the chemical. | |
| Her daughter Ann Marie Trante told the inquest how Dr Adel Mansur told her there had been "a terrible mistake". | |
| Checking failures | |
| She said he went down on his knees, held her hand and said he was very sorry for what he had happened. | |
| The coroner said it was difficult to imagine a more painful death and added: "We trust you to inject things into us. | |
| "The thought that some people in the NHS do not check what you give us is appalling." | "The thought that some people in the NHS do not check what you give us is appalling." |
| He said after the incident, no-one had checked for up to 14 hours as to whether there was an antidote. | |
| Public inquiry | |
| The family solicitor Guy Forster said a civil action on behalf of the family was likely to follow. | The family solicitor Guy Forster said a civil action on behalf of the family was likely to follow. |
| The chief executive of the hospital has issued an apology to Mrs McFarlane's family, which they said was "hollow" as it came 15 months after her death. | |
| Mr Forster said the McFarlane family were calling for a public inquiry because the Heart of England NHS Foundation Trust had only conducted an internal investigation so far. | |
| He said: "The trust says lessons have been learned but it's important the lessons are shared with other trusts so that no other family has to go through what the McFarlanes have." |