‘I just hope no other family ever has to go through this’
GRAN’S HEARTBREAK AS HOSPITAL’S ‘GROSS FAILURE’ AND NEGLECT CONTRIBUTED TO TODDLER’S DEATH
KAYDEN Urmston-Bancroft was a ‘bubbly, loving little boy.’
He was always on the go, always happy and always smiling.
Like most children, he was the centre of his family’s world.
But the toddler’s life was cut tragically short. And he spent his last few days in pain.
He needed an operation after it was discovered he had a hernia.
Medics at the Royal Manchester Children’s Hospital delayed carrying out the urgent procedure.
It was only after the 20-month-old was revived having gone into cardiac arrest – three days after he was admitted – that he was rushed to theatre. But it was too late. Two days later he died in intensive care after his life-support machine was switched off.
Kayden’s devastated mother was just 19-years-old.
She cradled her only child in her arms as he passed away while his gran read him Mr Men stories.
A coroner concluded that while the toddler died of natural causes, neglect played a part.
She said there were ‘missed opportunities’ to get Kayden to theatre.
‘Serious and basic failings’ and ‘unacceptable delays’ in his treatment were revealed over the course of a four-day inquest in Manchester.
Kayden’s grandmother, Julie Rowlands – who lived with the toddler and his mum Shannon Bancroft – spoke of her family’s heartbreak after yesterday’s hearing.
Julie, 46, revealed the devastating impact of Kayden’s death on her daughter, who is now 21.
“Kayden was a lovely, bubbly little boy with huge blue eyes,” she said.
“The day he went to hospital, he was as active as he always was. The stay in hospital was absolutely horrendous.
“We expected to take him to the hospital for him to have the operation, and him to be running around three days later.
“We never, ever would have expected what happened to happen.
“It has had a huge effect on our family and a massive effect on Shannon.
“Her nerves have been shocking. It’s been nearly two-and-half-years now. She’s contemplating never having another baby.
“She was only 19 when she lost Kayden.
“For a 19-year-old girl to go through having your baby put in your lap and the life-support machine turned off is more than enough for anyone.
“Hopefully, now the inquest is over, she can properly grieve for him.
“I don’t think she has yet because she wanted to know what had happened to him.”
Julie said the coroner’s conclusion has given the family some closure.
“It was the outcome I was hoping for because I knew he had been neglected,” she added.
“I saw it from day one and I was there every day.
“We saw a pattern of nobody coming, and not taking into account he was in so much pain.
“It was awful to see him like that. As far I’m concerned, Kayden died when he went into cardiac arrest.
“He was in so much pain and he couldn’t cope with it, and that contributed to the cardiac arrest.
“I just hope no other family ever has to go through this.”
The inquest earlier heard that Kayden, from Hillgate, Stockport, was born with a diaphragmatic hernia.
It was only discovered when he was taken to nearby Stepping Hill Hospital after falling from a bed and banging his face on April 12, 2016.
An x-ray showed that part of his bowel had burst through the hole in his diaphragm and he was transferred to Royal Manchester Children’s Hospital for urgent surgery.
Three days later, Kayden – in horrific pain and extremely distressed – was still waiting for the operation and went into cardiac arrest.
Doctors revived the youngster after 27 minutes before rushing him to theatre.
Kayden never regained consciousness. He died two days later.
Coroner Angharad Davies found Kayden died of natural causes, contributed to by neglect.
She said the ‘unacceptable delay’ in Kayden’s surgery was ‘sufficiently serious to amount to a gross failure.’
Ms Davies identified a number of ‘missed opportunities’ to perform the surgery and said there were ‘a number of serious and basic failings which meant Kayden was not operated on that week.’
The coroner, after hearing the evidence, found:
Deficiencies in the handover between on-call consultants between Tuesday, April, 12, and Friday, April 15, when Kayden was at RMCH.
Deficiencies in the management of the CEPOD list, a system of prioritising patients in need of emergency surgery.
A lack of understanding in the department about booking beds on the High Dependency Unit (HDU), where Kayden would have required support after his operation.
Failures to escalate concerns about Kayden’s condition. Nursing staff tried to escalate their concerns about his pain and distress with medical staff nine times, yet it was only recorded three times in the medical notes.
‘No real recognition’ of the pain and distress shown by Kayden when having oral intake. His family recall him screaming in agony after having a couple of mouthfuls of chocolate porridge on the Friday.
A lack of clarity in terms of which named consultant surgeon was responsible for Kayden.
At the time, the main reason for the delay in getting Kayden to surgery was said to be the lack of beds available on the HDU.
An internal review completed after his death showed a bed was not requested for Kayden until noon on April 15.
Records showed there were three beds available that day.
The court heard consultant surgeon Mr Mohamed Shoukry thought the bed for Kayden had been taken by another emergency.
Ms Davies said: “It is inexplicable to me why Mr Shoukry was under the impression that there was no HDU bed available on Friday.”
The coroner described it as a ‘basic, fundamental communication problem.’ “I do make findings of neglect based on the evidence,” Ms Davies told the court.
Addressing the family, she added: “You have my deepest sympathy on the loss of Kayden, and I can only imagine the devastating impact this has had on you.” Hospital bosses admitted there were ‘unacceptable’ delays and have apologised to the family. The trust in charge of RMCH says steps have been taken to ensure the same failings are not repeated. Following the inquest, Professor Bob Pearson, previously joint medical director and spokesperson for Manchester University NHS Foundation Trust, said: “We offer our sincere condolences to Kayden’s family and profound apologies for the lapse in standards which led to his death. The trust accepts the findings and conclusions of the coroner.
“As soon as Kayden died, we launched a rigorous and wide-ranging investigation to establish what had happened and put in place measures to ensure this does not happen again.
“We are grateful to the coroner for recognising the work undertaken by the trust and we wish to reassure the public that patient safety is our top priority.”
Stephen Clarkson, a clinical negligence specialist at Slater and Gordon, said: “No amount of money or apology will ever make up for the loss of their little boy, but the family hope that the hospital will learn from its mistakes, and that the changes the trust has put in place as a result of Kayden’s death will prevent any other children losing their lives in such terrible circumstances.”