Man died at QA Hospital in Portsmouth after 'gross failure' from hospital staff, inquest rules

Last week, an inquest into the death of 24-year-old Milo Peart concluded at Winchester Coroner’s Court, after Milo died at Queen Alexandra Hospital in Cosham on July 4, 2020.

Mr Peart, who had undergone two kidney transplants in his life, was admitted to QA Hospital after becoming incoherent on July 2. His mother raised concerns that he may be suffering from renal problems and low sodium levels, as he had during his kidney transplants. Doctors were concerned that he may have suffered a stroke – but this turned out not to be the case.

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The low sodium levels were indicating that Milo may be suffering from hyponatraemia, but this was not considered by doctors in their initial diagnoses, who instead focused on possible encephalitis and meningitis. During his time in hospital, his sodium levels continued to drop – and the coroner ruled he received no ‘appropriate monitoring’ for 16 hours. With his fluid balance increasing, he suffered a cerebral oedema, which is fluid on the brain.

On July 3, Milo had a complete cerebral and respiratory arrest, and died on the morning of July 4.

Giving a narrative conclusion, senior Hampshire coroner Christopher Wilkinson ruled that Mr Peart had suffered irreversible brain injury due to hyponatremia firstly caused by a fast intake of water and then by lack of appropriate treatment.

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These gross failures in care, he concluded, amounted to neglect.

He said: ‘A potential diagnosis of hyponatremia should have been considered earlier. I do feel on balance there were a number of missed opportunities to better treat Milo and his condition, particularly in the first 16 hours of his care.

‘As the hours went on it's less likely that there was a risk of stroke and given the background, which should have been recognised, there was a differential diagnosis that should have been considered.

‘In failing to consider the differential diagnosis I am of the mind that this was the tipping point in relation to the decision making and missed opportunities, but also a gross failure of medical care.’

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The court heard that Mr Peart was a creative and charismatic person, always putting his family first.

After the inquest, his family paid tribute to a ‘beautiful person’ who gave a lot of love to those around him. They said: ‘We are pleased to finally have answers to the questions that we initially raised almost three years ago. We are grateful to the senior coroner, who showed incredible empathy alongside a determination to get to the truth for Milo.

‘Nothing can bring Milo back to us and we, his parents and his two brothers, are devastated at his loss. He was a beautiful person, loved by many, who had an amazing future ahead of him. All of that is lost as a result of the failures of this hospital. We hope that there will, at least, be learning from this tragic event so that other families don’t have to go through what we have gone through.’

Dr Mark Roland, acting medical director at Portsmouth Hospitals University NHS Trust, said: ‘On behalf of Portsmouth Hospitals University NHS Trust, I would like to say how deeply sorry we are and again offer our condolences to Milo’s family.

‘This case has affected everyone involved including those who cared for Milo.

‘We will take the time as a team to reflect on the inquest’s findings to ensure that we continue to learn from this tragic case.’