Medics need training after patient died - coroner

More training is needed for hospital staff after a patient died from "a catastrophic and unsurvivable brain injury" following surgery, a coroner said.

It comes after patient John Rust, who had undergone a heart operation at Birmingham's Queen Elizabeth Hospital, died after a catheter leaked, Birmingham and Solihull's coroner Adam Hodson heard.

In the wake of the case, Mr Hodson has written in a report that all staff using cerebrospinal fluid drains, which the catheter was used for, should be "adequately trained" in their use.

The University Hospitals Birmingham NHS Foundation Trust, which has been asked to respond to the coroner by 15 December, said it had introduced extra safety measures.

The inquest heard Mr Rust had been admitted to the hospital on 25 March this year, for an elective thoracic aortic replacement.

It led to a cerebrospinal fluid catheter being inserted to minimise post-operative risks of paraplegia, Mr Hodson was told.

On 27 March, Mr Rust underwent surgery and was taken to an intensive care ward, where concerns were raised the drain was leaking, but the coroner said they were not acted upon.

The inquest concluded this caused him to suffer the major brain injury, and he died on 29 March.

In his Prevention of Future Deaths report, which was sent to the University Hospitals Birmingham NHS Foundation Trust, the coroner said: "In my opinion there is a risk that future deaths will occur unless action is taken."

He recommended that all clinical staff who use the cerebrospinal fluid catheter "must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use".

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Source: BBC News, 24 October 2025