A coroner today urged hospital managers to tighten procedures after the death of a four-year-old boy from Fareham.
Keith Wiseman said lessons needed to be learnt from the tragedy at Southampton General Hospital.
He had been told how Matthew Kenway, who suffered from a type of muscular dystrophy, died in the early hours of December 16, 2010 after being admitted to the high dependency unit after an operation on his kidney.
Doctors thought that Matthew was recovering well after the operation. But when he went into cardiac arrest, there was a delay of between 10 and 20 minutes in putting out a ‘crash call’ to summon staff to start resuscitation.
Today Mr Wiseman delivered a narrative verdict, saying there had clearly been a delay in proper response. ‘But the extent to which that was blameworthy is beyond my remit’ he said.
He recommended that hospital managers ensured there was proper training of staff, and regular reminders of the need to carry out a complete breathing and circulation check on a patient in the event of a suspected equipment malfunction.
He said the hospital authorities should also have a more appropriate escalation procedure in the event of an emergency.
Last week, the nurse on duty on the night Matthew died, Lyndsey Menendez, told the inquest that she initially thought the machine monitoring Matthew was faulty as his ventilator was still working.
An unqualified nurse also ‘ran’ to fetch a doctor, instead of following hospital protocol and putting out a ‘crash call’, which would have summoned a team of people.
Dr Kate McCombe, who attended the crash call, was questioned as to whether the delay could have been crucial to saving Matthew’s life.
She said: ‘Put very simply - yes.
‘Although, it depends on the underlying causes of the cardiac arrest, some can be irrecoverable.
‘In broad terms we are more likely to resuscitate someone if we recognise the cardiac arrest earlier.’