A grandmother of five died after gross medical negligence and failures in what should have been a routine procedure.

64-year-old Rosemary McFarlane was suffering with a lung condition which affected her breathing. She had a bronchoscopy carried out which should have been a routine test to check her lungs; it required her to have a phosphate solution injected in to her lungs.

Staff at the Heartlands Hospital Birmingham failed to notice prior to administering the phosphate solution to Mrs. McFarlane, a "10X" on the bottles label which referred to the concentration of the liquid.

This led to Mrs. McFarlane suffering burned lungs and was as pathologist Adrian Warfield described it, the "pivotal moment" which led to her getting pneumonia which killed her 10 days later.

Aidan Cotter the coroner said: "We trust you to inject things into us.

"The thought that some people in the NHS do not check what you give us is appalling." Adding it was difficult to imagine a more painful death and also pointing out that no-one checked to see if there was an antidote for up to 14 hours.

The McFarlane family solicitor has indicated that the family will take civil action probably resulting in a medical negligence compensation claim.

NHS complaints procedure should be pursued in all cases where negligence may have occurred if only so errors are highlighted and lessons can be learned by the NHS Trusts.

The chief executive of Heart of England NHS Foundation Trust, said: "We accept the coroner's verdict and deeply regret this tragic incident and again wish to apologise to Mrs. McFarlane's family."

He also said that changes have been made to the bronchoscopy procedure to ensure there will be no repeat of what happened to Mrs. McFarlane.

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