Dad 'burst into tears on train' after reading why his son had died

Officials have apologised to a grieving dad who missed an inquest which found serious failings by hospital staff into the care of his poorly son.

Lee Rawlinson wasn't told about the hearing into the death of his 12-year-old son due to an 'administrative error'. Mr Rawlinson only learned of the coroner's conclusion, that crucial delays in treating his critically-ill son who was born with heart problems, contributed to the death in a report of the hearing in his local paper.

Now, devastated Mr Rawlinson, 51, has said he has received and accepted an apology for an 'administrative error' after being told work was underway by the court to ensure no other parent, particularly those who have separated, suffer the same experience.

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Otherwise fit and healthy, Joel was on his PlayStation at home in Middleton when he collapsed on December 29, 2019. When he was taken to North Manchester General Hospital that night, medics concentrated on trying to find out the cause of the problems instead of recognising how poorly he was so he could be moved to a specialist children's hospital, the inquest heard.

Joel had successfully undergone major surgery just weeks after his birth to mend a damaged aorta, the main artery leading from the heart. However, the keen footballer for Middleton Lads fell seriously ill at home despite appearing to make a good recovery due to an aneurysm and later died in hospital from cardiac respiratory failure, reports the Manchester Evening News.

An internal NHS review into his death revealed medical staff should have considered transferring him to a specialist children's hospital by 1am on December 30, the day following his collapse. However, this didn't occur until around 9am when it was tragically too late, as was reported last month at the inquest held at Manchester Coroners' Court.

Lee Rawlinson with his son Joel Rawlinson
Lee Rawlinson with his son Joel Rawlinson -Credit:Lee Rawlinson

Mr Rawlinson has previously criticised the hospital for its 'sickening' failures. The inquest heard how overstretched hospital staff attempted to contact colleagues at Royal Manchester Children's Hospital directly instead of using the North West Transport Service (NWTS), which is the official channel through which district general hospitals are supposed to arrange transfers to Royal Manchester Children's Hospital or Alder Hey Children's Hospital.

Joel was stabilised and transferred to Royal Manchester Children's Hospital at 5pm the next day, but his condition sadly worsened again, the inquest heard. He was moved once more and arrived at Alder Hey at 7.15pm - suffering a cardiac arrest during the journey - and he underwent emergency surgery. Tragically, Joel passed away the following day at 2.20pm on January 1, 2020.

It was revealed at the inquest that staff at North Manchester General Hospital had employed an outdated method of fax to transmit key information about Joel, a practice which only came to an end in 2022. This, despite Joel's severely deteriorating health, and considerations to have him transferred to a regular children's ward at North Manchester, the inquest found out.

Area coroner Paul Appleton listed the formal cause of death as cardiac respiratory failure resulting from an aneurysm. He concluded that Joel's death was 'contributed to by the delay in recognising the severity' of his condition and the subsequent 'delay in escalating' his medical care.

Lee said he was unaware of the inquest details until he came across them in his local paper. He said: "I had a phone call from a coroners' officer who apologised and said 'we hold our hands up, it's our error'. He said I had a right to make a formal complaint and he would understand if I wanted to do that.

Lee, who has been separated from Joel's mum, Rachel Messenger, since 2018, continued: "There was no system in place to put in details if two parents have split up. It's been shocking and upsetting, the thought that people knew before I knew about my son's inquest, that they could have saved his life before his own father knew. That's what hurt the most really. I didn't know. People knew before me about my own son.

"I was going to work and I just burst into tears on the train. I didn't want people to see me upset. I was a bit embarrassed so I had to go home. I stayed in bed all day, crying."

Lee Rawlinson with his son Joel Rawlinson
Lee Rawlinson with his son Joel Rawlinson -Credit:Lee Rawlinson

He fondly remembered Joel, saying: "We were very close. He was my life, everything. He was a part of me. When he died, it was like a part of me died. We were really close. He was really sporty and had a really good sense of humour, joking all the time.

"He always put a smile on my face. We used to do park runs together, go jogging and go on bike rides together. He was a really fit lad. After what happened to him as a baby, there was no sign of anything wrong with him."

Lee said he rushed to North Manchester General when he heard his son had collapsed, and accompanied him to Royal Manchester Children's Hospital. He also travelled in the ambulance with him to Alder Hey Children's Hospital where his son underwent emergency surgery.

He last spoke to his son at North Manchester General before he was sedated, adding: "He had breathing difficulties. He said he was scared to me. The last thing I said to Joel was that he would be okay. They sedated him and I never spoke to him again."

Joel's mum Rachel Messenger told the inquest her son had said to her 'mum, I'm not feeling well', and had vomited blood and couldn't walk. After being informed about a new paediatric 'early warning score' introduced nationally which considered parental feelings, Ms Messenger told the court: "It doesn't change that our lives are wrecked. The people in this room know where these failings are. We know there are failings."

Ms Messenger said 'nobody knew what they were doing' even as her son was 'dying'. Both Dr Katherine Potier, a consultant in emergency medicine, clinical director at North Manchester General and Dr Imran Zamir, a consultant paediatrician at the hospital, agreed in retrospective that earlier intervention probably would have saved Joel's life. However, it is important to note that neither professional was directly part of the boy's care that tragic night.

Joel Rawlinson, 12, who died after collapsing at home on his Playstation
Joel Rawlinson, 12, who died after collapsing at home on his Playstation -Credit:Family handout

Dr Potier acknowledged no 'early warning score calculation' was executed for Joel on that night and mentioned the implementation of the 'Hive' digital patient records system, which introduced a national scoring system across the NHS. Additionally, she confirmed there was a delay in initiating a paediatric review that evening to escalate the case with senior consultants.

According to Dr Potier, there have been improvements at North Manchester post-tragedy. From the original six-and-half, now there are 16 consultants. Out of the 52 'actions' proposed by the review after the unfortunate event, all but three have been implemented, she said. She agreed that while staffing has reached 'much safer' levels at the hospital, there is still 'a distance to go'.

Manchester University NHS Foundation Trust previously stated: "We again offer our sincere apologies and condolences to Joel's family. We are committed to providing the best care possible for our patients, and we will be studying the coroner's decision very carefully to ensure that learning is identified and implemented."

The Manchester Evening News has approached Manchester Coroners' Court for a response.

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