Toddler inquest told of test not done at weekend

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.

He was described as having a “complex medical history” involving a congenital heart condition, which was being investigated by medics.

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.”

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

Christine Mann, Hillingdon matron and nursing services manager, apologised to Mr and Mrs Brown, saying one reason they were excluded was because of staff shortages.

She said: “I have no excuses. They should have been allowed to be with him throughout all the resuscitation.

“We learnt from this case about communicating and documentation.”

Although 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.

Hillingdon did not have the facilities to perform the test but the specialist hospital did.

Shankar Sridharan, of Great Ormond Street, said that although 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 to suggest 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 May 9 last year with trouble breathing and cold-like symptoms and 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.

But in the early hours of May 13 his condition deteriorated and doctors were unable to resuscitate him.

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

Coroner Lorna Tagliavini recorded a verdict of death from natural causes. She said there were no failings in Dylan’s care and he was treated “appropriately”.