Carl Marrows: New inquest finds boy's 1978 death a 'gross failure'
BBCA five year-old boy who died after undergoing surgery 43 years ago suffered a "gross failure of care", a coroner has ruled.
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 quashed by the High Court on appeal.
On Thursday, coroner Paul Marks said Carl's death may have been prevented with appropriate post-operative care.
In a narrative conclusion, senior Hull coroner Prof Marks said the death had been a "most unfortunate case".
Carl was born in 1972 in Scunthorpe and required multiple orthopaedic operations to treat his spina bifida - a condition which 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 his blood pressure began to drop after the operation and he died later the same day.
Prof Marks said staff were aware of his falling blood pressure but there was a delay in him being seen by an orthopaedic registrar.
'Total dignity'
Attempts to administer intravenous fluids were too late, he said, 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."
Dr Peter Reading, chief executive of Northern Lincolnshire and Goole NHS Foundation Trust, 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."
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