Fury as inquest finds no fault over toddler's death

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The Independent Online

The parents of a 23-month-old child who died during surgery after being shuttled between four hospitals in eight hours yesterday vowed to sue a health authority for alleged negligence after an inquest jury returned a verdict of death by natural causes.

Robert Benton died of acute bronchiolitis which kills only 1 per cent of child sufferers, although he was operated on for a suspected blockage to the windpipe at Heartlands Hospital, east Birmingham.

As the coroner, Dr Richard Whittington, directed the jury to return a verdict of natural causes and not to pass blame, the boy's parents Julie Benton, 23, and Timothy Dawes, 32, stormed out of Birmingham Coroner's Court.

Inside, relatives hurled abuse at chest surgeon Joseph Khalil Marzouk, who performed the bronchoscopy. He sat expressionless as they turned on the jurors. ``I hope your consciences are clear,'' yelled one.

Outside, Ms Benton, who is expecting her second child later this month, said: ``I feel that the summing up was very one-sided. When he first suggested natural causes as the verdict I felt sick. `I think there was more that could have been done. Robert had a chest infection but that was not life threatening. I feel he should still be here with us today.''

She claimed the coroner had overlooked evidence from independent surgeons and the pathologist who had disputed the treatment given to Robert.

Mr Marzouk said he died as a result of tracheo malacia, a birth defect which led to the collapse of his windpipe. However, pathologist Dr David Rushton said he had found no evidence of the rare congenital disorder despite three doctors in the operating theatre claiming they had identified the defect after discovering there was no foreign body or mucus blocking his trachea.

He said the post-mortem examination had shown that Robert died on 7 June last year of a double lung collapse caused by acute bronchiolitis. He claimed that as a result of artificial ventilation during surgery his diseased lungs had probably torn under the pressure and led to his death.

An independent consultant anaesthetist, Dr Roger Thornington, criticised the surgeon for not having inserted a chest drain which would have removed gases from his body and possibly saved his life. Had the bronchial infection been diagnosed at an early stage, he suggested, Robert could have been treated with antiobiotics and recovered in intensive care.

However, the coroner commented: ``I do not think we will ever be sure but the underlying cause of death was a naturally occuring infection.

``It would be naive to think that every death on the operating table is an accident or misadventure.''

Summing up the three-day hearing, the coroner recalled how Robert was taken by his parents to Sandwell Hospital near their home in Rowley Regis, West Midlands, but they left after 10 minutes, concerned at the chaos they found in the casualty department.

They drove him 10 miles to Good Hope Hospital, Sutton Coldfield, where doctors diagnosed a suspected blockage and organised a transfer to Birmingham Children's Hospital. On arrival, no beds were available so he was sent to Heartlands where he died during surgery, eight hours after first being taken to Sandwell.

The coroner said he did not believe the delay in treatment had affected the outcome, and in view of the fact that hospitals in the region had tightened the protocol for the transfer of patients, he did not feel the need to make any recommendations.

Solicitor Stephanie Forman, representing the family, said the verdict would not deter them from pursuing a case for alleged negligence against the West Midlands Rgional Health Authority: ``We feel we have every chance of winning and in addition we are going to instigate some form of inquiry into the findings of the inquest.''

A statement on behalf of the four hospitals visited by Robert said: ``Communications between hospitals were not clear and lack of clarity in communications is of serious concern to all the hospitals.

"New procedures have been put in hand. Now staff requesting a transfer are directed to contact a receiving hospital themselves to check that facilities are available before a transfer actually commences."