Inquest Concludes on Tragic Death Following Rare Heart Pump Failure
The grieving family of Luke Barnes have expressed that they feel "some closure" while acknowledging they will "never going to know" exactly why a critical component of his heart pump became disconnected, leading to his tragic death. The inquest into the 33-year-old father-of-three's passing concluded this week at Vantage House in Huntingdon, presided over by Coroner Elizabeth Gray.
Catastrophic Hemorrhage from Unexpected Disconnection
Luke Barnes, who lived in Mapperley, Nottingham, had his life support switched off on March 17, 2023, while awaiting a heart transplant at Royal Papworth Hospital in Cambridge. He had been receiving ongoing care at the hospital since 2022 after being diagnosed with cardiomyopathy in 2018, a chronic disease affecting the heart muscle. During his treatment, he was fitted with a BiVad mechanical pump system designed to assist blood flow.
Coroner Gray delivered a narrative conclusion, stating that Luke died from a "catastrophic hemorrhage" at approximately 5.40am on March 16, 2023, caused by a "disconnection" in part of his BiVad. She noted this event "couldn't have been predicted" and described it as a "rare" occurrence, with the exact cause of the disconnection remaining "unclear." The medical cause of death was recorded as multi-organ failure, severe haemorrhage and dilated cardiomyopathy resulting from the unexpected disconnection.
Nurses Describe the 'Horrific' Scene
During the first day of the inquest, two staff nurses who cared for Luke on the night of the incident gave compelling evidence. Nurse Thomas and Nurse Kuzniarz testified that they were together but "not far away" from Luke when they heard concerning sounds.
- Ms Thomas reported hearing a "sigh" while Mr Kuzniarz heard a "gasp"
- Upon approaching, Ms Thomas saw blood and discovered a "pool of blood" when she pulled back Luke's blanket
- She observed his cannula was disconnected and, seeing no blood in the cannula, reinserted it
- Mr Kuzniarz confirmed witnessing blood on Luke's bedding and described a "severe loss of blood" as a "horrific sight"
- Both nurses stated doctors were called "quickly" and they "proceeded with resuscitation"
Family Tributes and Search for Answers
On the final day of proceedings, Luke's mother Amanda Barnes and brother Glen Barnes paid emotional tribute to Luke while sharing their thoughts on the two-day hearing. Glen admitted the family were "a bit anxious" initially as they "didn't know what to expect," but after hearing the evidence, felt they would have "some closure that everything was done to standard."
Amanda described how Luke's death and the inquest has "hit us all hard," remembering her son as having a "personality no one could forget" and being "always up for a laugh." She added: "Luke had no filter. What you saw is what you got. Whether people wanted to hear about what he wanted to say, he just said it. He didn't pretend to be someone he wasn't." Amanda also mentioned Luke's love for football as a child and rugby later in life, concluding that "He will be in our hearts forever."
Coroner's Findings and Prevention Measures
During the inquest, family barrister Mr Thomas urged Coroner Gray to consider issuing a Regulation 28 report – a prevention of future deaths document. Such reports are issued when action is deemed necessary to prevent similar fatalities, with Mr Thomas pressing for NHS England to exercise "considerable vigilance" going forward to "minimise or alleviate risk of disconnection."
In her conclusions, Coroner Gray informed the court that medical staff had followed correct procedures for circuit changes and blood clot removal, and that there were no defects with the equipment required for the BiVad. She stated she discovered "no evidence" to contradict these points and backed evidence from Chalice Medical, the tubing manufacturers, that there was "no fault" with their product.
The coroner is now set to compile a comprehensive report aimed at preventing future deaths, ensuring that lessons are learned from this tragic incident while acknowledging the rarity and unpredictability of the disconnection that led to Luke Barnes' untimely death.
