Baildon teenager's parents vow to fight on after Coroner’s ruling

Steve and Anne Garner, of Ilkley, welcomed the Coroner’s narrative verdict which said staff failed to carry out basic observations on 18-year-old Laura Garner.

Sitting at Bradford Coroner’s Court, Assistant Deputy Coroner Professor Paul Marks said if such observations had been made and acted upon, Laura’s life could have been saved.

Professor Marks used his powers to make two Rule 43 reports – a report which allows a coroner to raise issues of concern with the organisation responsible in order to prevent any more deaths arising from the same failings.

He will write to the director of nursing at Bradford Teaching Hospitals NHS Foundation Trust to raise concerns about the taking and recording of patients’ observations, a concern he will also share with other local and national organisations, and he will write to the medical director of the trust over continuing concerns about its crash trolleys.

A defibrillator on ward 11’s crash trolley did not work when Laura went into cardiac arrest and another crash trolley had to be found. Prof Marks said while he did not believe this contributed to Laura’s death, it was a matter of concern which should be addressed.

Laura was admitted to BRI on September 22 with abdominal pains. Doctors suspected appendicitis or a urinary tract infection. She underwent a laparoscopy on September 23, which excluded appendicitis and returned to ward 20 in the afternoon.

In his narrative verdict Prof Marks said: “After the procedure, no basic observations were carried out on her until 21.30 on September 23, 2009 when her blood pressure was unrecordable.

“Such observations, if made, are likely to have shown evidence of deterioration and, if acted upon, may have permitted therapeutic intervention.”

After the inquest her parents said they hoped the Rule 43 reports would prevent any other families going through their ordeal.

“We have the outcome we wanted but there are no winners in this because we can’t bring Laura back,” said Mrs Garner. “But we did not want her death to go unnoticed. If we can stop any other families going through what we continue to go through, then we will have achieved what we wanted.”

Mr and Mrs Garner paid tribute to their “bubbly, lovely girl who lived life to the full”.

“When Laura died we had 300 people at her funeral and her friends set up a Facebook page where they put 1,300 dedications,” they said.

Mrs Garner revealed that they sold their Baildon home after Laura’s death because they could no longer bear to live there without her. They moved to Ilkley and Laura’s ashes are buried in the town’s cemetery, which Mr Garner said he visited nearly every day.

The couple said it was the love and support of their family, including Laura’s elder sister Jennifer, mother to their two grandchildren, Evie, two, and three-year-old Isabelle, that had helped them through.

“Laura is back and living with us in our youngest granddaughter Evie, who is just as bubbly as Laura,” added Mr Garner.

Mr and Mrs Garner plan to continue their legal action.

After the inquest, a spokesman at the foundation trust said: “We would like to reiterate our sincere condolences to Laura’s family. The foundation trust has taken Laura's death extremely seriously and we acknowledge that Laura’s care fell below an acceptable standard for which we apologise unreservedly.

“The foundation trust took immediate action to investigate the circumstances surrounding this tragic loss of life and launched an extensive patient safety initiative called Safe!, in a committed and sustained effort to improve the care of the acutely unwell inpatient. The Safe! campaign has brought about real improvements in clinical practice which remain in place today throughout our hospitals.

“The foundation trust accepts fully the findings of the inquest and recognises that there are additional lessons to be learned for all medical and nursing staff. The foundation trust will act upon the findings as a matter of urgency.”