Kate Wilson was recently instructed on behalf of the family of a patient who died after undergoing surgery for a left peri-prosthetic hip fracture following a fall. The Deceased, aged 54, sadly died in Medway Maritime Hospital three days’ post-surgery after developing a paralytic ileus (a type of intestinal blockage or pseudo-obstruction caused by a malfunction of the nerves and muscles in the intestine and is a common side effect of trauma or surgery). As a result, he experienced nausea and vomiting for several days prior to death and his family were concerned that this was not properly recorded, monitored or treated. The medical cause of death was confirmed as 1(a) aspiration pneumonia (caused by aspiration 3-5 days prior to death as well as a significant aspiration of gastric contents on the day of death) due to 1(b) bowel pseudo-obstruction and gastro-oesophageal reflux. Over a four-day inquest, the clinical management of the Deceased’s symptoms were thoroughly explored which included the clinical decision not to insert a nasogastric tube 48 hours prior to death, whether there were any missed opportunities to identify and treat the underlying pneumonia and the standard of nursing care provided.


The Coroner, sitting in the Mid Kent and Medway Coroners’ Court, recently handed down her findings and narrative conclusion remotely. Following targeted questioning by Miss Wilson regarding the completion of basic nursing observations and monitoring of symptoms, the Coroner found that the Deceased’s fluid balance charts were not fully completed on several days whilst in hospital, stool charts were not accurately completed and his NEWS observations were often not taken within the recommended monitoring frequency (including shortly before death). The Court heard that observations were delayed on the date of death due to the ward being short staffed. The Coroner reserved her position regarding a Regulation 28 Report (a report to prevent future death) and requires Medway NHS Foundation Trust to inform her in writing as to what action has been taken to address those matters.


Kate Wilson has recently been ranked in the Legal 500 as an inquest specialist: (“Extremely diligent and thorough and able to get on top of the issues”) Legal 500 (2021). Family concerns regarding medical negligence often go unrepresented at inquest due to the lack of legal aid funding, however a targeted approach by an advocate can give the family reassurance, advice and the guidance that make the inquest an easier process to navigate and ultimately provide peace of mind that their concerns are thoroughly explored.

For further information about Kate or any member of the team please contact the Regulatory & Public Law clerks:

Madeleine Gray on 0113 202 8603

Patrick Urbina on 0113 213 5250