A CORONER has called for “lessons to be learned” after hearing about delays in medical staff spotting that a boy’s heart was failing.
Matthew Kenway had seemed to be recovering well from a kidney operation at Southampton General Hospital but his heart stopped suddenly and he died.
Devastated parents Katie Oxley and Anthony Kenway are now considering legal action against the trust which runs the hospital.
Delivering his narrative verdict yesterday Southampton coroner Keith Wiseman said: “There was clearly a delay in recognising that there had been cardiac arrest.
“Obviously the passage of any such time could have affected the likelihood of resuscitation being effective.”
Mr Wiseman highlighted an NHS report urging better checks for breathing, circulation and consciousness.
He added: “There was also to be training and reminders to nursing staff on the appropriate escalation process in an emergency situation arising – that is to say, the calling of the cardiac arrest emergency team before physically calling for help to someone nearby, however close.”
The exact cause of Matthew’s heart attack remains a mystery.
Southampton Coroner’s Court was told how after the surgery Matthew was looked after on the paediatric highdependency unit but in the early hours the oxygen monitor probe appeared not to be recording anything. A nurse initially thought the machine might be faulty, but it turned out that Matthew’s heart had stopped.
It emerged Matthew had not been hooked up to a heart monitor and that treatment may have been delayed because an unqualified nurse ran to bring a doctor, rather than raising a cardiac arrest alarm.
University Hospital Southampton NHS Foundation Trust said following Matthew’s death it had now introduced heart monitoring for all infants and children who have had surgery.
Trust director Dr Michael Marsh said: “This was an extremely sad case and our thoughts remain with Matthew’s family following a very difficult period for them.
We continue to offer his family our full support.”
But Dr John White, representing Matthew’s family said: “The evidence we have heard raises grave questions about the quality of care Matthew received and the processes that were in place at Southampton General Hospital at that time.”
Matthew, who suffered from a type of muscular dystrophy, was four years old when he died on December 16, 2010. He had a congenital condition that made his muscles weaker than usual so he relied on a home ventilator and had a tracheostomy to breathe.
Last night his adoring family paid tribute to a little boy who loved life.
In a joint statement, they said: “He was an inspiration to us all. He loved life and sometimes we had to tell him to slow down and rest.
“We always said that his two strongest muscles were his brain and his heart.
“We are very sorry that he did not get to meet his little brother Taylor Matthew. He would have loved being a big brother.”