Toddler Died 'After Test Not Done'

A sick toddler died in hospital after an important heart test was not done because it was the weekend, an inquest has heard.

Dylan Brown died in Hillingdon Hospital, Uxbridge, west London, on May 13 last year after suffering three cardiac arrests.

The two-year-old, who had an underlying cardiomyopathy, disease of the heart muscle, could have had an echocardiogram (ECG) which uses sound waves to create a picture of the heart.

Dr Nagi Barakat, a consultant paediatrician at Hillingdon, told the inquest at West London Coroner's Court: "It was not done because it was the weekend and they are not normally done at the weekend."

He did not say why they are not normally done at this time.

As attempts were made to resuscitate the toddler, his parents were not allowed into the room with him.

Christine Mann, the hospital's matron and nursing services manager, apologised to them, saying one reason they were excluded was because of staff shortages.

She also apologised for the parents, feeling they were not given enough information about discussions involving Dylan.

She said:

"I have no excuses.

"They should have been allowed to be with him throughout all the resuscitation.

"They should most definitely have been with him.

"We learnt from this case about communicating and documentation.

"We clearly didn't communicate with Dylan's family effectively when staff were adjusting and silencing his monitor.

"We should have been more clear to the family about what was happening at that time."

Though Dylan, of Uxbridge, was being treated at Hillingdon, Dr Barakat was in telephone contact with a children's heart specialist from Great Ormond Street Hospital to discuss the case.

Dr Shankar Sridharan, the medic from Great Ormond Street Hospital, said though an ECG would have helped, there was no reason to conduct one at the time.

He said that when he was contacted about Dylan's case on the day before he died there was no clinical evidence the youngster needed an ECG.

Dr Sridharan said:

"If someone called this weekend with the same information we would do the same thing.

"We wouldn't arrange an urgent transfer if there were no clinical signs."

The specialist added, with hindsight, an ECG would have been beneficial and would have suggested other drugs might have benefited the child.

He also said Dylan had an ECG 12 months earlier which he had seen and which reassured him.

Dylan was admitted to hospital on Wednesday May 9 last year with trouble breathing and cold-like symptoms.

Over the next few days his heart rate rose and fell.

The inquest heard a normal range for a two-year-old was between 70 and 130 beats per minute.

Dylan's heart rate the day before he died went up to 190 but he was playing in his cot and displayed no signs of heart failure, the hearing was told.

In the early hours of Sunday May 13 his condition deteriorated and Dr Barakat was called in to treat him.

Dylan began suffering cardiac failure. He was given adrenalin and intubated to help his breathing and he was moved to an operating theatre to use its ventilator.

After the third resuscitation Dr Barakat and a registrar decided "the outcome was very poor" and they should stop trying to resuscitate him.

"It is a sad story," said Dr Barakat. "It touched everybody and touched me as well because I can put myself in the parents' shoes. I have lost two children as well.

"It's a sad story. Everyone has done their best to help. I sincerely give my condolences to the family."

Pathologist Lina Kiho said the cause of the death was "dilated cardiomyopathy".

She said the post-mortem examination showed the toddler's heart was enlarged and his lungs had a viral infection which contributed to his death but did not cause it.