A series of failures caused the death of a 64-year-old grandmother who was undergoing a routine procedure, a coroner ruled today.
Rosemary McFarlane died after being given a fatal dose of a medical product which was 10 times the recommended concentration.
She was being treated at Heartlands Hospital in Birmingham for pulmonary fibrosis, a lung condition which affected her breathing.
The inquest heard that she needed a routine test called a bronchoscopy to check her lungs.
But the solution she was given was highly acidic and burnt her lungs.
In a narrative verdict, supplied by the coroner's office, Coroner for the City of Birmingham Aidan Cotter said: "Mrs McFarlane was 64 years old and suffered from pulmonary fibrosis.
"She was significantly ill but not at risk of dying.
"In order to find out exactly what was wrong with her so that she could be treated most effectively, she underwent a procedure at Heartlands Hospital on August 12, 2008, in which a solution was poured into her right lung.
"Because of a series of failures by the hospital staff, the solution was 10 times more concentrated than it should have been.
"That caused her death.
"Mrs McFarlane died because she was given a medical product which was 10 times more powerful than was intended.
"Neglect contributed to her death."
Chief executive of Heart of England NHS Foundation Trust, Dr Mark Goldman, said: "We accept the coroner's verdict and deeply regret this tragic incident and again wish to apologise to Mrs McFarlane's family.
"Following a detailed investigation, which has been shared in full with the family, changes have been made to this specific procedure to ensure that this will not happen again."
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