What should the healthcare system learn from Marina Young’s Inquest?

The recent inquest into the death of Marina Young – a disabled woman who waited 39 hours in A&E while experiencing an asthma attack – highlights key systemic issues in healthcare settings. The inquest at Preston’s Fulwood Court in September 2024 revealed that prolonged waiting times and inadequate monitoring directly contributed to her death.

These findings reflect broader problems within the healthcare system, particularly around resource allocation and patient care protocols.

In cases like this, inquests serve as essential tools to uncover failings that may not be apparent during routine reviews. While an inquest does not assign legal blame, it identifies critical factors that contributed to the patient’s death. This process enables healthcare providers to see where lapses have occurred, making it possible to address these failings through targeted changes in practices.

The inquest findings in this case underscore the urgent need for healthcare institutions to evaluate their emergency care systems, and ensure that they have the resources necessary to prevent similar incidents.

Marina Young and common medical failings

Marina Young, a 46-year-old woman with spina bifida and asthma, tragically died after being left in a hospital chair for 39 hours at the Royal Preston Hospital in June 2022. Despite her clear health deterioration, staff failed to properly assess her condition or transfer her to intensive care.

The inquest revealed significant failings in her care, with the coroner, Dr James Adeley, ruling her death was caused by gross neglect. The lack of adequate medical attention, including missed opportunities for timely intervention, contributed to her worsening breathing difficulties, which ultimately led to her death.

The inquest revealed significant failings in her care, with the coroner, Dr James Adeley, ruling her death was caused by gross neglect

The coroner highlighted that hospital staff failed to escalate Marina’s care appropriately, despite her condition deteriorating over several days. No attempt was made to move her to intensive care, and medical teams misjudged the seriousness of her symptoms. Her family, particularly her sister Michelle, welcomed the coroner’s verdict, which confirmed that her death could have been prevented with proper care.

As a result of this case, a Prevention of Future Deaths Report will be issued to highlight the failings and urge improvements to prevent similar incidents in the future. This ruling has raised concerns about the level of care provided to vulnerable patients within the NHS.

The findings from the inquest into this case highlighted specific medical failings. Marina Young was left unattended for hours, with exceedingly long delays in receiving treatment. This delay was not an isolated incident, but part of a pattern of inadequate response times and lack of critical patient monitoring. The coroner cited these delays as contributing to Marina’s death, underscoring the consequences of failing to provide timely care in emergency settings.

Legal and ethical implications

The findings from this inquest bring legal and ethical implications to the forefront. Legally, healthcare providers are obligated to deliver care that meets established standards. In this case, the findings suggest a breach of this duty, as the patient did not receive timely medical intervention. The coroner’s report highlighted how these failings could warrant further investigations, potentially leading to civil claims or disciplinary actions against the staff involved.

Ethically, the responsibility extends to address and prevent similar incidents, which is facilitated by seeking to learn from these failings. Healthcare institutions must examine their protocols and make necessary adjustments, particularly in emergency care settings where the risk of harm from delays is heightened. This case serves as a reminder that healthcare providers have a duty not only to their patients, but also to the wider public to maintain standards that prevent avoidable harm.

Marina’s prolonged wait time and lack of monitoring also raise questions about resource management in A&E departments. Healthcare providers should prioritise reviewing their triage processes to ensure patients in critical conditions are promptly identified and monitored. This could take the form of implementing stricter guidelines for patient oversight, especially during peak times when delays are more likely.

This might include designating specific personnel to monitor high-risk patients and implementing technology that alerts staff to changes in a patient’s condition. These changes can help ensure that patients receive timely attention, even when emergency departments are under pressure.

Healthcare systems might consider integrating tools that allow for real-time patient tracking, helping staff to quickly identify those who need immediate attention. Additionally, by reviewing and potentially restructuring staffing patterns, healthcare providers can ensure that resources are distributed to reduce waiting times and improve the accuracy of patient assessments during peak periods.

Healthcare providers can implement structured training programmes focused on emergency care protocols, triage procedures and communication practices. Training sessions that emphasise real-life scenarios may assist staff in better preparing for situations where delays or lapses in monitoring could lead to adverse outcomes. Additionally, periodic assessments of staff competency in emergency care procedures can help ensure that all personnel are equipped to meet the demands of their roles.

Regulatory scrutiny and Marina Young

The coroner’s findings in this case could lead to scrutiny from regulatory bodies. These organisations, such as the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC), are responsible for investigating the conduct of doctors, nurses and midwives who have made errors and/or have shown a repeated pattern of poor care.

A report noted that systemic issues contributed to Marina’s prolonged wait, suggesting that individual healthcare workers may not be solely at fault. However, the role of regulatory bodies is to ensure that any professionals whose actions fall short of expected standards face appropriate consequences.

These bodies may conduct their own inquiries, examining whether the staff involved acted in accordance with professional standards. Potential disciplinary actions could include suspension or further training requirements. Such oversight serves not only to address individual cases but also to uphold public trust in the healthcare system by demonstrating a commitment to accountability.

The responsibility to learn from this inquest

The case surrounding Marina Young’s death has had a profound impact on her family, particularly her father, who never recovered from the loss. He passed away before the conclusion of the inquest, which only further highlights the devastating emotional toll this event had on her loved ones.

While the inquest findings bring some closure, the verdict comes too late for both Marina Young and her father, leaving her family with lingering grief and unanswered questions about the care she received in her final hours. The inquest confirmed that her death could have been avoided had proper medical attention been provided.

The NHS must take active steps to address the gaps in patient care, particularly in cases involving vulnerable individuals like Marina, who may require more attentive monitoring and faster escalation to critical care services

Although the inquest conclusion serves as a recognition of the failures that occurred, the NHS must take these findings seriously to ensure similar incidents do not happen again. The purpose of such inquests is not only to provide justice to the victims and their families but also to shine a light on systemic issues that require urgent reform.

The NHS must take active steps to address the gaps in patient care, particularly in cases involving vulnerable individuals like Marina, who may require more attentive monitoring and faster escalation to critical care services. Failing to learn from this tragedy could result in repeated harm to other patients.

The significance of this inquest lies in its potential to drive tangible changes within healthcare settings. It emphasises the importance of accountability, ensuring that lessons are learned and that hospital systems evolve to prevent similar cases of neglect.

Implementing new policies and practices around patient monitoring, care escalation, and communication within medical teams is essential to achieving this. Marina’s case, though tragically too late for her, can serve as a catalyst for these improvements, ensuring that no other family has to endure the same heartbreak and loss due to avoidable negligence in hospital care.

Each of these failures contributes to a broader picture of systemic weaknesses in handling cases that require urgent and sustained medical attention. By recognising these patterns, healthcare providers can take steps to improve training, communication, and response protocols to prevent similar outcomes, and prevent the occurrence of clinical negligence.

Madeleine Langmead is a Solicitor in Medical Negligence at JMW Solicitors

Madeleine Langmead

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