Vital delays in treatment led to boy’s death
Inquest hears heartbroken mum slam hospital ‘fiasco’
CRUCIAL delays in treating a critically ill 12-year-old old boy with a history of heart problems after he collapsed and was admitted to a hospital A&E contributed to his death, a coroner has concluded.
Joel Thomas Rawlinson was on his Playstation at home in Middleton when he collapsed on Sunday night, December 29, 2019.
But when he was brought into 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 that he could be moved to a specialist children’s hospital, an inquest heard.
Joel had undergone successful major surgery just weeks after his birth to repair a damaged aorta, the major artery coming from the heart.
But the youngster, who recovered well and loved playing football for Middleton Lads, collapsed at home because of an aneurysm
and later died in hospital of cardiac respiratory failure.
An internal NHS review of his death found medics should have discussed transferring him to a specialist children’s hospital by 1am the following day, December 30, but this didn’t happened until around 9am when it was too late, an inquest at Manchester Coroners’ Court was told on Monday.
The inquest heard ‘stretched’ hospital staff tried to phone colleagues at Royal Manchester Children’s Hospital instead of using the North West Transport Service (NWTS), through which district general
hospitals are supposed to arrange for transfer to Royal Manchester Children’s Hospital or Alder Hey Children’s Hospital.
Staff were even said to have used a fax to send over key information about Joel, an archaic practice that is said to have ended only in 2022.
Despite how poorly Joel was, consideration was even given to moving the boy onto a regular children’s ward at North Manchester, the inquest was told.
Dr Mike Enthwhistle, a consultant anaesthetist with NWTS, arrived at North Manchester General at 12.20pm, the inquest heard, but Joel was considered too unstable to be moved at that stage.
He was stabilised and moved to Royal Manchester Children’s Hospital at 5pm but his condition deteriorated again, the inquest heard.
The child was moved again and arrived at Alder Hey at 7.15pm - going into cardiac arrest on the journey - and he underwent emergency surgery.
He died the following day at 2.20pm on January 1, 2020.
Dr Graham Mason, a consultant in paediatric care at Royal Manchester Children’s Hospital who carried out the review, told the inquest doctors and nurses who initially looked after Joel at North Manchester General ‘failed to recognise the seriousness of his illness’ when he was admitted as they attempted to diagnose what had caused his sudden collapse.
The doctors who saw him should have recognised the patient who presented with low blood pressure had collapsed ‘without any apparent cause.’
Dr Mason noted there was ‘a significant amount of focus around what the potential diagnosis was rather than acknowledging how severely unwell Joel was’ and that there ‘should have been further escalation’ when it was obvious he wasn’t improving with the treatment he was receiving around midnight on the night he was admitted to A&E.
He said medics should have considered administering further fluids at that time and, if this didn’t work, considered transferring him to a specialist children’s hospital by 1am.
Such a discussion didn’t take place until around 9am, the inquest heard.
Joel’s condition was ‘absolutely’ time-critical, said Dr Mason who said the child required specialist paediatric intensive care support.
Dr Mason said Joel probably would have survived ‘if these steps would have happened earlier’ and he could have gone into theatre sooner.
He said Joel’s condition was ‘rare’ but he went on: “It’s not an issue to recognise the exact diagnosis but I think the key issue was to recognise how critically ill Joel was and the blood pressure was a sign of that.”
Dr Mason said he had found no evidence that a paediatric ‘early warning score’ had been used and he said that it was no longer the practice to fax notes to different hospitals following the introducing of a new information system by the NHS, called Hive, in September 2022.
The doctor acknowledged staff at North Manchester felt ‘particularly stretched’ especially in paediatrics that night.
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 Dr Mason explained a new paediatric ‘early warning score’ had been introduced nationally which took account of parental feelings, Ms Messenger
said: “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 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.
Earlier, Ms Messenger said that her son was vomiting for a week after he was born and later had two operations at Alder Hey Children’s Hospital to repair his aorta.
After his collapse and being admitted to North Manchester General, she told the inquest the number of people who seemed to be involved in his care at various times that night was ‘horrific’ and that ‘nobody knew what they were doing’ even though her son was ‘dying.’
When the inquest resumed, Dr Katherine Potier, a consultant in emergency medicine and clinical director at North Manchester General, and Dr Imran Zamir, a consultant paediatrician at the hospital,
both agreed Joel would probably have survived with earlier recognition of how poorly he was.
Neither was directly involved in his care that night.
Dr Potier accepted there had been no ‘early warning score calculation’ done for Joel on the night, adding that the ‘Hive’ digital patient records system had introduced a national scoring system across the NHS.
She also accepted that there had been a delay in the instigation of a paediatric review that night so that the case could be escalated with senior consultants at home.
The number of consultants at North Manchester had been raised from sixand-a-half to 16 since the tragedy, said Dr Potier, who went on that all but three of 52 ‘actions’ suggested by the review following the tragedy had been implemented.
She said staffing was now at ‘much safer’ levels at the hospital although she accepted there was ‘a distance to go.’
Area Coroner Paul Atherton recorded the medical cause of death as cardiac respiratory failure due to an aneurysm, and concluded the death was ‘contributed to by the delay in recognising the severity’ of Joel’s condition and by ‘delay in escalating’ his treatment.
Joel’s family declined to comment following the hearing.
Manchester University NHS Foundation Trust said in a statement: “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.”
“There are big failings. I hope everyone can sleep well in their beds tonight”