Faulty diagnosis led to toddler's death

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The Independent Online

A 23-month-old child who died on an operating table after he was taken to four hospitals in eight hours could have survived had the correct diagnosis been made, an inquest heard yesterday.

Robert Benton died of acute bronchilitis, which kills only 1 per cent of child sufferers, Birmingham Coroner's Court was told.

But he had been operated for on a suspected blockage to the windpipe, which led to his death. A paediatric pathologist, David Rushton, explained that the artificial ventilation performed by doctors during surgery had contributed to his death, on 7 June last year.

His parents Julie Benton, 23, and Timothy Dawes, 32, were told by the consultant chest surgeon, Joseph Khalil Marzouk, that Robert had died of tracheo malacia, a congenital disorder in which the cartilage holding open the windpipe collapses. He said it was a birth defect that would have killed him sooner or later.

Earlier, the couple had taken Robert to Sandwell hospital, near their home in Rowley Regis, West Midlands. Concerned at the "chaos" that they found in the casualty department, they drove him 10 miles to Good Hope hospital, in Sutton Coldfield. After a suspected blockage to the airways, caused by a mucus plug or a foreign body was diagnosed, he was transferred to Birmingham Children's hospital.

But on arrival no beds were available, so he was sent to Heartland Hospital for a bronchostomy. Mr Marzouk, who performed the operation, said he made Robert a priority, but was unable to find a blockage obstructing his breathing.

"On withdrawal of the bronchoscope it became clear there was a severe degree of tracheo malacia," he said.

His condition was deteriorating due to a tear in his left lung, which caused air to fill his body and his heart stopped twice. Despite efforts to resuscitate him, he died at 9.12 p.m.

A pathologist, Dr David Rushton, said the artificial ventilation performed by the doctors contributed to his death. "I could not find any evidence of a congenital disease. The diagnosis of tracheo malacia was mistakenly entertained."

He said acute bronchilitis was the underlying cause of death but it was also due to the pneumothorax, a gap between the lung and the windpipe, which was prompted by the artificial ventilation. "The effects of the treatment contributed materially to his death."

Roger Thornington, a consultant paediatric anaesthetist from the Alder Hey Hospital in Liverpool, called to give expert evidence, agreed the pneumothorax occurred during the treatment. He criticised Mr Marzouk for not inserting a chest drain, which would have removed air from the body and possibly saved his life. Earlier, the surgeon had insisted he ruled out the procedure because he had not known of the existence of a pneumothorax.

Dr Thornington accepted the need for a bronchoscopy because of the suspicion of a blockage to the windpipe. He said he was surprised the surgeon and his two anaesthetists had diagnosed tracheo malacia.

"It is unusual because the child had not shown any typical signs of the rare disorder such as a sharp cough," he said.

The jury are expected to return a verdict today.