Represented by Rothera Bray’s Serious Injury team, the family has endured a long and deeply distressing process in their search for answers about how an essential piece of medical equipment – the aortic cannula tubing connected to Luke while he was on BIVAD (Biventricular Assist Device) support – became disconnected.
Despite detailed questioning from the Coroner and the family’s legal representatives, the Trust was unable to provide any evidence explaining how the tubing came to be detached. The Coroner heard clear evidence confirming that the tubing system is designed to be secure and robust and could not have been inadvertently dislodged by routine movement.
A further significant issue identified during the inquest was the discarding of the medical device involved, despite regulatory requirements to retain such equipment for investigation following a catastrophic “never event.” Evidence heard suggested the Trust did not have a clear understanding of its reporting and investigative obligations, resulting in the equipment being disposed of before it could be examined by independent experts. This meant that key avenues of investigation were permanently lost.
In the absence of both physical evidence and any explanation from the Trust, the Coroner determined that the cause of the disconnection could not be identified, leaving Luke’s family without the answers they have waited almost three years to receive.
Concerns raised during the inquest go beyond this single incident and speak to broader issues surrounding the Trust’s handling of serious incidents, including accountability, governance, and basic patient safety practices.
Throughout the hearing, the Coroner heard several critical pieces of evidence, including:
- When the disconnection was discovered, Luke had already lost a significant proportion of his circulating blood volume. One responding nurse confirmed she observed no blood flow in the aortic cannula tube, the site of the disconnection.
- Two days before the incident, Luke’s tubing had developed a blood clot, which required suctioning during a routine circuit change.
- The Trust does not routinely monitor tube pressure in patients supported by a BIVAD device, relying instead only on flow rate and pump revolutions per minute.
Following the conclusion of the inquest, Luke’s widow, Isobel, has spoken publicly not about the legal findings, but about the man her husband was:
“Following the conclusion of the inquest, I feel it’s important to speak as Luke’s wife — not in legal terms, but from my heart, to share who my husband truly was, beyond the courtroom and the headlines.
“Luke was my love, my safest place and my greatest joy, my best friend and my home. He was the person who made me feel safe, loved and understood. Being married to him was a privilege I will carry with me for the rest of my life.
“He was an incredible father, so proud and so full of love. Our family was the centre of his universe. Luke had the biggest heart and loved fiercely. He stood up for what he believed in and protected the people he cared about with everything he had. To be loved by him was to know what unconditional love truly meant and to lose him has left a void that can never truly be filled. Life without him feels quieter, heavier, and unimaginably painful. Losing him has shattered my world in ways words will never fully capture. Every day without him is a struggle, and the ache of his absence is constant.
“Luke had the most infectious laugh and a wicked, cheeky sense of humour that could lift the heaviest of moments. He made people feel comfortable, valued and seen just by being himself. Behind the jokes and macho rugby player frame, he was the kindest soul — loyal, passionate and endlessly giving.
“The inquest may be over, but our grief is not. Luke is not a case, a conclusion or a headline — he is my husband, a father, and a treasured and missed family member and friend. He is missed in every breath I take, and he will be loved for as long as I am here. He lives on in the memories we hold, the love he gave so freely, and in the lives of those he touched simply by being himself.
“I ask for kindness and compassion as we continue to navigate life without him, holding onto the memories, the love, and as we honour Luke’s life and carry his love with us always.”
Abagail Clarke, a Solicitor in Rothera Bray’s dedicated Inquest team said:
“The family’s priority now is ensuring that meaningful lessons are learned and that no other family experiences a similar tragedy. The issues highlighted during the inquest raise significant concerns about the Trust’s investigative processes and must prompt urgent review and reform.
“At this time, the family ask that their privacy is respected as they continue to process their loss and navigate life without Luke.”
