Luke Jenkins
Luke Jenkins 

Luke's inquest took place at Avon coroner's court on the 11th of November until the 21st of November 2013, the coroner was Maria Voison. During the inquest we heard from over 30 witnesses involved in Luke's care, most of which we believe failed to accurately describe the events of Luke's hospital stay. Throughout the inquest we remained confident and hopeful that the coroner would see that from the evidence that was presented to her through our barrister (Adam Korn), solicitor (Laurence Vick), ourselves and independent expert evidence along with the CQC report and the root cause analysis and child death review that she would determine that the Hospital failed Luke and caused his death. The hospital solicitor was Louise Wiltshire of DAC Beachcroft.


Although the outcome was that the coroner decided there was no 'gross negligence' we were advised prior to the inquest that the purpose of the inquest was not to establish any blame but to find out where and how Luke had died. Here is a link to an explanation of the verdict from our solicitor Laurence Vick.



We were very upset and dissapointed with the outcome and although the coroner suggested she was happy with the changes that the hospital had made since Luke's death we feel that she could have gone further with her summing up and narrative verdict. As part of the changes the hospital setup a new high dependency section which they claim cost them £1 million, however they were also the only children's heart unit in the United Kingdom to not have a high dependency unit prior to this change.


By making these changes since Luke and other children's deaths we feel it is an admission in itself as using £1 million of NHS funds at this current time would not be carried out without great scrutiny and an actual need for the service, this was also highlighted by the hospital trust as a previous issue prior to Luke's death but unfortunately they left it hanging and did not carry it out allowing children to go without specilaist high dependency care.

We are glad that the hospital have now made changes which will benefit children in the future and make it a safer place for them and also make their families feel hopefully safer, we only wish the hospital had acted on this prior to all the children dying.


There will be upcoming media coverage surrounding the outcome of the Bristol Cardiac review along with Luke's PHSO report so please return to the website where you will be able to view the reports in full once they are publsihed