Officials apologise to father who was not told of son’s inquest
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 our sister paper the Manchester Evening News (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.
Joel had undergone successful major surgery 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, fell severely ill 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 of December 30, the day after the collapse, but this didn’t happened until around 9am when it was too late, the inquest at Manchester Coroners’ Court was told last month.
His father, Lee Rawlinson, has previously slammed the hospital for its ‘sickening’ failures. 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.
Joel was stabilised and moved to Royal Manchester Children’s Hospital at 5pm the following day, but his condition deteriorated again, the inquest heard. He was moved again and arrived at Alder Hey at 7.15pm - going into cardiac arrest on the journey and he underwent emergency surgery. Joel died the following day at 2.20pm on January 1, 2020.
The inquest heard staff at North Manchester General 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.
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.
Joel’s father, Lee Rawlinson, 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 said he didn’t know about the details of inquest until he read about it in the M.E.N.
The train company manager tsaid: “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 went on: “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 always put a smile on my face. We used to do park runs together, go jogging and go on bike rides together.
“He was a really fit lad. After what happened to him as a baby, there was no sign of anything wrong with him.”
He said reading about the failures in his care 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 said he went to Lee’s bedside at North Manchester General when he learned he had collapsed, and joined him at Royal Manchester Children’s Hospital. He said he went in the ambulance with him to Alder Hey Children’s Hospital where his son underwent emergency surgery.
He 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,” said Lee.
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. 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’.
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’.
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.”
I was going to work and I just burst into tears on the train. I didn’t want people to see me upset LEE RAWLINSON ON MISSING HIS SON JOEL’S INQUEST