Devastated dad accepts apology from coroner’s office over inquest error
OFFICIALS have apologised to a grieving father who missed an inquest which found serious failings by hospital staff into the care of his poorly son.
Lee Rawlinson wasn’t told about the hearing into the death of his 12-year-old son due to an ‘administrative error.’
Mr Rawlinson only learned of coroner’s conclusion, that crucial delays in treating his critically-ill son, who was born with heart problems, contributed to the death in a report of the hearing in the M.E.N.
Now devastated Mr Rawlinson has said he has received and accepted an apology for an ‘administrative error’ after being told work was underway by the court to ensure no other parent, particularly those who have separated, suffer the same experience.
Otherwise fit and healthy, Joel was on his PlayStation at home in Middleton when he collapsed on Sunday night, December 29, 2019. When he was taken to North Manchester General Hospital that night, medics concentrated on trying to find out the cause of the problems instead of recognising how poorly he was so he could be moved to a specialist children’s hospital, the inquest heard.
Area coroner Paul Appleton recorded the medical cause of death as cardiac respiratory failure due to an aneurysm. He concluded the death was ‘contributed to by the delay in recognising the severity’ of Joel’s condition and by ‘delay in escalating’ his treatment.
Lee, 51, from Heywood, went to Joel’s bedside at North Manchester General when he learned of the collapse. He split from Joel’s mother in 2018. Lee, a train company manager, told the M.E.N.: “I had a phone call from a coroners’ officer who apologised and said ‘we hold our hands up, it’s our error.’ He said I had a right to make a formal complaint and he would understand if I wanted to do that.”
Lee said he accepted the verbal apology and decided not to make a formal complaint after receiving assurances the court was working to ensure it never happens again.
He said the official blamed an ‘administrative error,’ adding: “There was no system in place to put in details if two parents have split up.”
Lee added: “It’s been shocking and upsetting, the thought that people knew before I knew about my son’s inquest, that they could have saved his life before his own father knew. That’s what hurt the most really. I didn’t know. People knew before me about my own son.”
When the M.E.N. first reported the blunder, Lee said: “I was going to work and I just burst into tears on the train. I didn’t want people to see me upset. I was a bit embarrassed so I had to go home. I stayed in bed all day, crying.
“We were very close. He was my life, everything. He was a part of me. When he died, it was like a part of me died. We were really close. He was really sporty and had a really good sense of humour, joking all the time.”
He said reading about the failures in his care in the M.E.N. left him ‘sick to the stomach.’
He added: “We sort of knew there had been mistakes in a report from the hospital which said there were recommendations going forward.
But nobody said at the time ‘we could have saved Joel if we had [followed] different processes.’
“It just makes me feel sick. I spoke to him and told him he was going to be okay and he passed away. To think they could have saved him if they had been quicker, it’s terrible. It’s devastating and really hard to live with that now.”
Lee spoke to his son for the last time at North Manchester General before he was sedated, adding: “He had breathing difficulties. He said he was scared to me. The last thing I said to Joel was that he would be okay. They sedated him and I never spoke to him again.”
Joel’s mother, Rachel Messenger, told the inquest her son had told her ‘mum, I’m not feeling well,’ and had vomited blood and couldn’t walk.
After she was told a new paediatric ‘early warning score’ had been introduced nationally which took account of parental feelings, Ms Messenger told the court: “It doesn’t change that our lives are wrecked. The people in this room know where these failings are. We know there are failings.”
She said her son had been left in A&E ‘with smackheads’ and he needed to be transferred to a specialist children’s hospital.
“There are big failings. I hope everyone can sleep well in their beds tonight,” she said. Becoming upset, she said her son’s treatment had been a ‘fiasco’ before walking out of the hearing.
The number of consultants at North Manchester had been raised from six-and-a-half to 16 since the tragedy and all but three of 52 ‘actions’ suggested by a review had been implemented. Manchester University NHS Foundation Trust said in a statement at the time: “We again offer our sincere apologies and condolences to Joel’s family. We are committed to providing the best care possible for our patients, and we will be studying the coroner’s decision very carefully to ensure that learning is identified and implemented.” The M.E.N. asked Manchester Coroners Court for a comment.
The last thing I said to Joel was that he’d be okay. I never spoke to him again Lee Rawlinson