The coroner concluded there had been a “consistent failure” to consider information in Marina’s medical records and information that her sister, who had previously worked as a nurse, had written down when she was admitted.
The inquest heard Marina, who was from Ribbleton and had spina bifida, was unable to go to the toilet or remove her shoes.
This caused intense pain if she wore them for too long when an asthma attack was taking place.
Dr Adeley said “one of the saddest and most upsetting aspects” of Marina’s case was that she was still wearing shoes when her sister saw her after she had died, despite the pain it would have caused her.
“I could smell urine. It was so strong it was awful,” her sister Michelle told her inquest.
The coroner said a box had consistently been ticked on a form in Marina’s records indicating that her hygiene needs had been met, despite there being no evidence she had been given any help to use the toilet.
The form was “little more than a tick box exercise”, he told the hearing.
Family solicitor Madeleine Langmead, from law firm JMW, said: “Marina’s case is likely to have implications for the treatment of other vulnerable patients, particularly those suffering an asthma attack and should improve their patient safety.”
