Overview
- Coroner Elizabeth Gray delivered a narrative conclusion that Luke Barnes, 34, died after a catastrophic haemorrhage caused by an unexpected disconnection in part of his BiVAD at around 5:40 a.m. on March 16, 2023.
- The event was described as rare and unpredictable, with the precise cause of the disconnection remaining unclear and no evidence indicating a procedural lapse.
- Medical staff were found to have followed correct protocols, the tubing manufacturer reported no product fault, and the hospital introduced mitigations such as cable ties and heightened vigilance during circuit changes.
- Testimony detailed how nurses discovered heavy bleeding, observed a disconnected cannula, reinserted it, and called a resuscitation, with evidence noting the cannula–tubing interface is typically fixed and not replaced during routine swaps.
- The family expressed partial closure despite a lack of definitive answers, while their solicitor raised concerns about the disposal of the device and investigative obligations as the coroner considers possible safety actions.