Medics need training after patient died - coroner

John Rust died from a "catastrophic and unsurvivable" brain injury, following a heart operation at Birmingham's Queen Elizabeth Hospital, in March this year

More training is needed for hospital staff after a patient died from "a catastrophic and unsurvivable brain injury" following surgery, a coroner said.

It comes after patient John Rust, who had undergone a heart operation at Birmingham's Queen Elizabeth Hospital, died after a catheter leaked, Birmingham and Solihull's coroner Adam Hodson heard.

In the wake of the case, Mr Hodson has written in a report that all staff using cerebrospinal fluid drains, which the catheter was used for, should be "adequately trained" in their use.

The University Hospitals Birmingham NHS Foundation Trust, which has been asked to respond to the coroner by 15 December, said it had introduced extra safety measures.

The inquest heard Mr Rust had been admitted to the hospital on 25 March this year, for an elective thoracic aortic replacement.

It led to a cerebrospinal fluid catheter being inserted to minimise post-operative risks of paraplegia, Mr Hodson was told.

On 27 March, Mr Rust underwent surgery and was taken to an intensive care ward, where concerns were raised the drain was leaking, but the coroner said they were not acted upon.

The inquest concluded this caused him to suffer the major brain injury, and he died on 29 March.

'Risk of future deaths'

Mr Hodson said his death could have been avoided if concerns surrounding the leak leak been acted upon sooner.

In his Prevention of Future Deaths report, which was sent to the University Hospitals Birmingham NHS Foundation Trust, he said: "In my opinion there is a risk that future deaths will occur unless action is taken."

He recommended that all clinical staff who use the cerebrospinal fluid catheter "must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use".

Mr Hodson acknowledged that currently the training was not mandatory and, at the time of the inquest, he heard that approximately only 55% of the relevant staff had received the training.

"We extend our deepest condolences to the family and loved ones of Mr John Rust," said a spokesperson for University Hospitals Birmingham.

Following his death, the trust said it had carried out a detailed investigation and introduced a number of additional safety measures.

The coroner had acknowledged the improvements made in response to Mr Rust's death and the trust was working to ensure that all further actions required are carried out promptly in line with the report.

That included establishing a sustainable training framework for the monitoring of lumbar drains.

"The Trust remains committed to maintaining the highest standards of patient safety and to learning from all patient safety events," the spokeperson added.