As a result of the circumstances surrounding Colin’s death, Hazel and her family approached us in order to seek answers through an inquest process.

The inquest uncovered exactly how the fatal error had occurred. The nurse advising Colin, and administering the vaccinations, was very well qualified. She had a good understanding of the contraindications and knew that the live attenuated yellow fever vaccine should never be given to someone with Colin’s history. However, when asking about his medical history the information was taken verbally. Colin volunteered that he’d previously suffered a benign thymoma, but the nurse misheard (in part due to Colin’s accent) and thought he said that he’d had a benign spinal tumour. The first meant that a yellow fever vaccination was contraindicated, the second did not.

Senior Coroner Mary Hassell, who heard the inquest was concerned about how this fatal mistake had arisen and questioned why better safeguards weren’t in place. She felt there was a risk that future deaths would occur unless action was taken and, accordingly, she prepared a Prevention of Future Deaths Report.

The Coroner’s concerns were two-fold:

• “The recording of medical conditions was entirely dependent on the verbal communication, which in this instance was sub optimal…There seems to be a need for an added layer of security, rather than just relying on patients listening to a long list of conditions being read out.
• MASTA currently has no way of auditing whether the record a nurse makes is accurate.”

As a result of the inquest and claim processes, MASTA, the clinic responsible for providing the vaccination to Colin, made a number of improvements. These not only address the specific concerns of the Coroner but went even wider:

• They changed the prompts the nurses used to clarify the language used, and to include reference to ‘thymus gland’ and to ‘thymectomy’. The prompts are separated out into two parts to mitigate the risk of this key medical history being missed or answered mistakenly.
• Improved links were made on the MASTA system to alert staff to the risks of yellow fever vaccines for some patients
• The traveller’s vaccination booklet was expanded to include more detail about yellow fever side effects
• A mandatory training module specifically focusing on the thymus gland and the effects of its removal was developed and completed by all MASTA nurses involved in advising and administering vaccinations
• The contraindications for the vaccination were highlighted and moved to the top of the Patient Group Directive for the product and reissued to all MASTA nurses.
• Digital pads were trialled so confirmatory signatures could be obtained by travellers to approve the history taken.

As a result of active participation in the inquest the family were able to secure changes to MASTA’s systems which should ensure this doesn’t happen to anyone else.

After representing the family in the inquest process, in August 2018 Hazel sought compensation through a fatal claim. We obtained expert evidence and issued court proceedings on behalf of the family. Ultimately, we secured a settlement of £380,000. A significant proportion of this was to compensate the family for the loss of income they suffered as a result of Colin’s death.

The settlement not only provided the family with financial security for the future, but also helped them to achieve a sense of closure about what happened. Through having specialist representation in the inquest and the subsequent claim the family were able to answer the questions they had about how Colin’s death came about. This included obtaining evidence from medical experts who undertook in-depth analysis about Colin’s death and what went wrong, and hearing first hand evidence from key witnesses involved in Colin’s case. Crucially, the family have achieved something positive as part of Colin’s legacy: the lessons learned through the process have led to key safety improvements being made at MASTA which mean nobody else should go through what they did.