This week I have been supporting a family through one of the most difficult situations often linked to our work as clinical negligence claims solicitors – an inquest into the unexpected and avoidable death of a loved one.
It is never easy to prepare a family for all that an inquest can entail, other than to warn them that it is highly likely that upsetting details will be revealed, and that they could hear things they disagree with which may leave them unhappy.
For the family of Sheila Hynes, who died following errors made during heart surgery at the Freeman Hospital in Newcastle, it has proved just that way.
They have come away from the proceedings feeling they still haven’t been given all the answers as to how and why things went wrong, and that the surgeon responsible hasn’t been fully held to account.
Even with the scope of this particular inquest being extended at our request to consider a possible breach of human rights, there was not a feeling of closure for the family, and in inquests where coroner’s record narrative conclusions – which effectively are a summary of the events which unfolded – this can often be the case.
Coroner’s role is not to apportion blame but to establish facts around death
One of the key messages we have to stress to families ahead of an inquest is that the role of the coroner is not to apportion blame.
A coroner’s role is to establish who has died, where they died, when they died and how they came to their death.
This is not to say, however, that the findings of an inquest, and the summary of a coroner, cannot play an important role when a legal case is ongoing.
Indeed, this week’s inquest into the death of Ms Hynes has highlighted many aspects of the case and led to comments which further underline the failings of the surgeon and the hospital during, and after, her operation.
Coroner Karen Dilks was clear in stressing that opportunities were missed to identify and rectify the position of a heart valve when it was inserted wrongly, causing Mrs Hynes acute heart damage from which she could not recover.
The inquest has also crucially played a very important role in identifying that of four similar products manufactured world-wide, only one cannot be inserted upside down. It is an issue of wider concern.
As a result of this case, the coroner said she is writing to the Newcastle upon Tyne Hospitals NHS Foundation Trust and to the regulatory body with a view to speeding up a redesign of the valve mounting to prevent it being held in an inverted position in the future.
Although too late for Mrs Hynes, it is of some comfort to her family that the case, and the media attention it has generated, could prevent similar errors being made in the future.
Legal case will now seek civil redress for failings on behalf of Mrs Hynes’ family
As this case has highlighted, our experience is key in explaining where the inquest fits in the ongoing process of making a legal claim.
The next step now for Mrs Hynes family, who have bravely and honestly expressed their heartache and frustration throughout the case, is to bring the legal claim to a successful conclusion.
Sadly, it can never turn back the clock and bring back their much-loved and missed mother and grandmother, but it can ensure people are held to account, and hopefully that vital lessons are learned to prevent similar tragic events in the future.