AN “extraordinary set of circumstances” contributed to a delay in treating a four-year-old boy who died at Southampton General Hospital, an inquest heard.
Matthew Kenway’s heart stopped as he recovered from a kidney operation.
But staff said they could not have anticipated that the youngster’s condition would deteriorate the way it did because his breathing was normal.
Staff nurse Lyndsey Menendez told the Southampton inquest how she had been caring for Matthew, of Bellfield, Fareham, in the children’s high dependency unit while another nurse was on her break.
She was at this point the only qualified nurse caring for four patients – usual practice is one for every two.
During the night, Matthew’s readings had not given cause for concern, the inquest heard.
But after an alarm sounded on Matthew’s oxygen and pulse monitor, a ‘trace’ could not be found, the inquest was told.
Ms Menendez said she saw Matthew was breathing and therefore thought it must be a problem with the equipment, so replaced it. But when she massaged Mathew’s feet she realised there was a problem with his circulation and then could not detect a heartbeat.
Despite attempts to resuscitate Mathew, who had a lifelong muscular condition called congenital fibre-type disproportion, he died at about 4.20am on December 16, 2010.
A post-mortem concluded that Mathew had more than likely died from a kidney infection.
John White, representing Mathew’s family, said an NHS investigation into the death had found that there was a 20- minute delay between the alarm and medical staff attempting to resuscitate the youngster.
But Ms Menendez believed it was actually five to ten minutes.
She added that it was “incredibly rare” that a patient had a cardiac arrest without first a deterioration in breathing.
Ms Menendez said if Matthew had been linked to a heart monitor she would have known what the problem was immediately, but using them was not standard practice at the time.
Following Matthew’s death all patients at the hospital are linked to a heart monitor for the first 24 hours after surgery, the inquest heard.
The inquest also heard how the NHS investigation had found that the delay in recognising Matthew was in arrest and the failure to follow hospital policy, when the healthcare assistant had not called for the crash team immediately, “may have prevented the chance of a recovery”.
Dr Gary Connett, consultant respiratory paediatrician who had been caring for Mathew most of his life, agreed there had been a delay in recognising heart failure, but said that delay was “entirely understandable”
given Mathew’s unusual lack of breathing problems.
“This is an extraordinary set of circumstances,” he said.
The two-day inquest was due to finish today.