Hospital's neglect led to toddler's death, inquest finds

Kayden Urmston-Bancroft, aged 20 months, was admitted to the Royal Manchester Children's Hospital on April 12 2016 for surgery on a diaphragmatic hernia but suffered a cardiac arrest on April 15 and died two days later.

On Thursday, coroner Angharad Davies found Kayden died of natural causes, contributed to by neglect.

She said the "unacceptable delay" in Kayden's surgery was "sufficiently serious to amount to a gross failure".

She identified missed opportunities to perform the surgery and said there were "a number of serious and basic failings which meant Kayden was not operated on that week".

The four-day inquest heard Kayden, from Stockport, had been transferred from Stepping Hill Hospital and placed on a list of patients requiring emergency surgery.

His medical notes said there was no bed available in the hospital's high dependency unit (HDU), so he was not able to have the operation.

The notes said his mother Shannon Bancroft was "very upset" at the delay, but recorded that she was told by his consultant that Kayden remained well.

A report compiled after his death showed a bed was not requested for Kayden until midday on April 15 and records showed there had been three beds available that day.

The court heard consultant Mohamed Shoukry had thought the bed for Kayden had been taken by another emergency.

Ms Davies said: "It is inexplicable to me why Mr Shoukry was under the impression that there was no HDU bed available on Friday."

She said there had been a "basic, fundamental communication problem".

She told the court there had also been "confusion" over who the consultant with responsibility for Kayden's care had been.

In a statement, Kayden's family said: "Kayden's death has devastated our family. He has left a huge hole that cannot be filled and we miss him every day.

"Time doesn't make it any easier and knowing that he could have been saved is hard to bear.

"You take your child to hospital and you think everything will be alright, that they'll be able to make them better. We put Kayden's life in their hands and they let us down in the worst way possible.

"We begged them to help him over and over, but instead we had to watch him fade away. He died in pain and that's the thing I don't think we can ever forgive.

"By the end it was clear he was giving up and while it broke our hearts, we had to make the decision to let him go."

Stephen Clarkson, a clinical negligence specialist from law firm Slater and Gordon, representing the family, added: "This is a highly-respected children's hospital, but what we have heard is evidence of a disorganised system where certain staff were unaware of procedure and who was in charge.

"What resulted was that no one took accountability for Kayden's care until, tragically, it was too late."

Following the conclusion of the inquest, Jonathan Holl-Allen, representing the trust, said: "It would be appropriate for me to repeat at the conclusion of these proceedings the apology that the trust has given to members of Kayden's family."

Professor Bob Pearson, previously joint medical director and spokesman for Manchester University NHS Foundation Trust, which runs Royal Manchester Children's Hospital, said: "We offer our sincere condolences to Kayden's family and profound apologies for the lapse in standards which led to his death.

"The trust accepts the findings and conclusions of the coroner.

"As soon as Kayden died, we launched a rigorous and wide ranging investigation to establish what had happened and put in place measures to ensure this does not happen again.

"We are grateful to the coroner for recognising the work undertaken by the trust and we wish to reassure the public that patient safety is our top priority."

Story by Press Association