Parents of quadriplegic teen who died at Leeds General Infirmary 'disappointed' at coroner's decision

Adam Bojelian, who had quadriplegic cerebral palsy, died in March 2015 after infections caused his organs to fail, an inquest at Wakefield Coroner's Court heard.

The inquest heard that Zoe and Paul Bojelian had a number of concerns about the care their son received at Leeds General Infirmary, and believed he could have lived longer if he had been treated in an intensive care unit earlier.

But coroner Kevin McLoughlin said he did not believe that was the case.

Mr McLoughlin said: "Neither the location of his treatment within the hospital or the care he received made more than a minimal contribution to his death.

"The death should be attributed to natural causes."

In a statement following the inquest, Dr and Mr Bojelian said: "We are surprised and disappointed by the coroner's verdict."

The couple continued: "We believe that Adam shouldn't have died in the way he did and this continues to traumatise us."

Adam suffered a severe brain injury at his birth in 2000 and developed quadriplegic cerebral palsy and epilepsy, among other conditions.

He was admitted to hospital in September 2013 and his condition began to deteriorate from November 2014.

Mr McLoughlin said antibiotic treatment became less effective and Adam needed a more sophisticated ventilator to help him breathe, which nurses on the paediatric ward had no previous experience of using.

Adam's parents wanted him to be cared for in a paediatric intensive care unit (PICU), but he was not transferred until the end of February 2015.

He initially showed signs of improvement after his transfer, but his condition began to deteriorate on 5 March, and he was deemed to be critically ill four days later.

He died in a hospice on 24 March 2015.

Mr McLoughlin said Adam was seen by at least 10 "dedicated, competent, caring" consultants during the seven weeks before his transfer to the PICU, and none considered that he needed to be moved.

He added he had heard no evidence that the ward nurses' inexperience with the ventilator caused any harm to Adam.

The coroner said that Adam's deterioration was an "inevitable consequence" of his condition.

"PICU was not a panacea," he said.

He added: "Despite all possible treatment, Adam's decline could not be arrested."

However, the coroner said he would contact Leeds Teaching Hospitals NHS Trust over concerns that the Trust did not keep records of training received by individual nurses and did not write a formal care plan during 15 months of Adam's stay in hospital.

Dr and Mr Bojelian welcomed the coroner's acknowledgement of their concerns, and said they were pleased at the attempt to prevent any potential future harm to patients.

They added: "We are saddened by a lack of support and compassion from Leeds Teaching Hospitals since Adam's death, and we hope that those with the power to do so will work to prevent a repeat of the circumstances that combined to make Adam's final weeks so difficult."

Adam's parents paid tribute to their son following the inquest, which concluded on Monday after being adjourned in September.

They said: "It is impossible to sum Adam up in a few words. He achieved more in his 15 years than most achieve in a lifetime, despite the immense challenges he faced on a daily basis.

"Adam wrote multi-award-winning poetry, was a vocal advocate for patient rights, and helped to raise tens of thousands of pounds for charities."

Mr McLoughlin praised Adam's parents for their dedication to their son throughout his life and since his death.

He said: "I wish again to pay tribute to the tenacity and conviction of Dr and Mr Bojelian in fighting for their son's rights."

He added: "Your efforts as parents are truly outstanding."

David Berridge, Leeds Teaching Hospitals NHS Trust's deputy chief medical officer, said the trust would study the coroner's comments carefully.

He said: "We are determined to learn lessons and have already implemented a lot of changes since Adam's sad death. We hope his family are reassured by this."

Mr Berridge added: "All of the staff who cared for Adam throughout his hospital admission were saddened by his death. We offer our sincere condolences to his family on this difficult day."