New inquest finds five-year-old boy's 1978 death a 'gross failure'

A five year-old boy who died after undergoing surgery 43 years ago suffered a "gross failure of care", a coroner has ruled.

The boy, Carl Marrows, who had spina bifida, died from "massive blood loss" after the operation in Scunthorpe in 1978.

A 1986 inquest heard he died of natural causes but the conclusion was later quashed by the High Court on appeal.

Coroner for the East Riding of Yorkshire and Hull, Prof Paul Marks, said Carl's death could have been prevented with appropriate post-operative care.

In a narrative conclusion, Prof Marks said the death had been a "most unfortunate case.”

Carl Marrows was born in 1972 in Scunthorpe and required multiple orthopaedic operations to treat his spina bifida, a condition that affects spinal development.

In February 1978 he underwent a tendon transfer procedure at Scunthorpe General Hospital to correct problems affecting the stability of his right hip.

Hull Coroner's Court heard that Carl started haemorrhaging blood just hours after his operation; his blood dropped dramatically after the operation and he died later the same day.

It was found that Carl's life could have been saved if hospital staff had put a cannula inside his arm to allow for a blood transfusion before he was discharged onto the ward.

Prof Marks said staff were aware of his falling blood pressure but there was a delay in him being seen by an orthopaedic registrar.

He added that attempts to administer intravenous fluids were too late and there had also been some incomplete documentation.

Summing up his findings, he said: "For the avoidance of doubt, Carl's condition was known to those caring for him, appropriate action was not taken and this amounts to a gross failure and there is a clear and direct causal relation to Carl's subsequent death."

He said Carl's family, who attended the hearing virtually, had acted with "total dignity" despite the passage of 43 years.

He added: "I hope this enables them to gain some degree of closure after years of uncertainty."

Chief executive of Northern Lincolnshire and Goole NHS Foundation Trust, Dr Peter Reading, said: "We would like to extend our sincere condolences to Carl's family. Nothing can take away the pain of losing a loved one, no matter how much time passes, but we hope that this new inquest verdict brings them some closure."