A top coroner has today concluded that there were no failures in the care of a little boy who died aged just 18 months old. Henry Kenworthy, who suffered from Noonan Syndrome and heart condition hypertrophic cardiomyopathy, was taken to hospital by his worried parents with a chest infection - and died two days later.
The 'joyful and cheeky' little boy caught enterovirus and was admitted to hospital on March 3 2019 after he began struggling with breathing. Consultant paediatricians gave a working diagnosis of bronchiolitis and he remained in hospital, where his condition then quickly 'spiralled'.
An inquest last Wednesday (June 28) heard how his worsening condition could've been raised sooner with senior doctors by paediatric nurses and that the cardiac arrest he subsequently suffered may have even been avoidable. However, at the inquest conclusion on July 8, Area Coroner Zak Golombek said that there were no failures in his care and that Henry died of "naturally occurring illnesses that reached their natural end."
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Despite his underlying health complications, mum Nicola previously told the court that Henry was 'just a normal 18-month-old boy' who was active, healthy and progressing well before his hospital admission. She also said 'lots of mistakes were made', adding: "He was so poorly and I could see that. I don’t feel confident at all that should another Henry turn up presenting in the same way, anything different would happen.
“We don’t want to blame somebody, but I felt like we weren’t taken seriously and that nobody could see what I was seeing. In hospital it just felt very chaotic. He was really poorly and I kept trying to explain but I felt nobody could see it or was listening."
After being admitted on March 3, Paediatric Specialist Registrar Dr. Jalisatgi assessed the youngster and gave him high flow oxygen, IV fluids and antibiotics. He remained mostly stable throughout the night, but his condition then worsened the following morning.
At around 6.20am, (March 4) it was decided that he also needed a nebuliser. Reflecting back, Dr Jalisatgi admitted it was at that point that she could have alerted a more senior paediatric consultant at the hospital, as he began to deteriorate further.
"Upon reflection, perhaps this may have been my mistake. I could have made the call and escalated this to the consultant at that point in time," she told the court.
Just over an hour later, it was then decided that Henry needed to be moved to the High Dependency Unit (HDU) at the hospital, where he would be hooked up to a ventilation machine. He had begun wheezing and 'working harder' to breathe, before his condition 'quickly spiralled' further, according to Paediatric Consultant Dr Elizabeth Wilkins.
After the 18-month-old had moved units, Henry was still requiring a lot of oxygen to keep him breathing, and cannulas had stopped proving effective. Despite further measures, little Henry's heart rate started dropping, and he suffered a cardiac arrest at around 10.49am.
Following his death, experts clinicians Dr Duncan MacRae and Dr Simon Nadel constructed a report into the care that Henry received. Both of them agreed that Henry’s care should’ve been escalated to a more senior consultant paediatrician earlier on the morning of March 5, when an assessment revealed he was deteriorating - especially in light of his other underlying health conditions.
Their joint report also outlined that there were further delays in making contact with a Paediatric Intensive Care Unit (PICU) and the North West Transfer Service (NWTS), who should've been called sooner. They also agreed that Henry should then have been intubated sooner, where a tube is inserted into the mouth or nose for air to get through.
Had that happened, they believed he may have been ‘stabilised’ and survived long enough to then be moved to a more specialist paediatric unit elsewhere. They suggested his cardiac arrest may have been preventable. However, the hospital trust said they decided against this at that point due to the high risk complications involved, which could've caused Henry to suffer spasms.
The court heard how Henry suffered a cardiac arrest at 10.49am, and was then tragically pronounced dead shortly afterwards at 11.12am on March 5. Despite concerns previously raised in court about the delays in aspects of Henry's care, Coroner Zak Golombek concluded on Friday (July 8) there had been no failures, and that the hospital staff acted appropriately under the difficult circumstances.
He said: "Henry was born in September 2017 at Wythenshawe Hospital and he died at the same place just 18 months later. At a very young age he was diagnosed with Noonan syndrome and hypertrophic cardiomyopathy.
"I want to pay tribute to his family. We have heard how Henry was a funny, happy and joyful little boy. His family have sat and listened through very difficult evidence with an incredible amount of dignity and respect. For the 18 months of his short life he had so much love and comfort around him."
Coroner Golombek recorded a conclusion of natural causes, adding that "naturally occurring illnesses reached their natural end". After considering post mortem evidence, he recorded the medical cause of death as 1A hypertrophic cardiomyopathy and enterovirus, and 2A Noonan Syndrome.
Speaking after the inquest, mum Nicola said she 'can't understand' why the coroner came to the conclusion that her son's death was natural. She pointed to expert medical guidance discussed during the inquest which said Henry's death may have been avoided.
"After today, we are shocked and unbelievably disappointed with the findings," Nicola told the MEN.
"We don't know where to go next with this but all we have ever wanted is a public acknowledgement of the failings in Henry's care.
"Henry was an amazing little boy. He brought us so much joy in his 18 short months and taught us so much about life and love and what's possible.
"He was clever, funny and made our lives better. We miss his beautiful face and cheeky smile, and wish he was still here with us."
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