Action should be taken after a toddler died by choking at Butlins in Bognor

A coroner has said lessons must be learned after a toddler choked on a sausage at a holiday park.

Two-year-old James Manning, who had enlarged tonsils and suffered “dozens of choking attacks” before his death, choked on sausage with his family at Butlin’s in Bognor in June 2018.

Despite CPR and first aid, the sausage could not be removed and it took paramedics seven to eight minutes to remove the piece of food using a laryngoscope and Magill forceps.

James went into cardiac arrest lasting seven to eight minutes, causing hypoxic ischemic brain injury caused by lack of oxygen in the brain.

He was stabilized and taken to Southampton General Hospital where, despite being treated in intensive care, he was removed from life support and died on June 20, 2018, two weeks after the incident.

Read more: The tragic death of the toddler at the holiday park was an accident – investigation results

Assistant Medical Examiner Karen Harrold concluded at James’ inquest in March 2021 that his death was an accident but that the boy had been “abandoned” because “red flags” had been missed regarding his enlarged tonsils.

James from Battle was well known to his GP and the local hospital (Conquest Hospital) as he had had several episodes of choking.

“The NHS has let James down as a previous intervention may have reduced the likelihood that James would die on June 6.

And now Ms Harrold raised several concerns with the NHS and Butlin’s in a new report on preventing future deaths.

The Argus: James ManningJames Manning

She said GPs and physicians could benefit from national guidance to ensure greater consistency is achieved when referring children for tonsillectomy and similar treatments, and that further guidance might be appropriate to help physicians decide in which Cases requiring urgent referral to hospital or tertiary care and inclusion of asphyxia in the ENT UK Commissioning Guide for Tonsillectomy.

She also expressed concern at the delay in James’ reassessment and referral for further treatment, particularly after he was referred for a sleep study due to concerns about sleep apnea, which was made worse by staff furloughs.

And she said systems used to review how information is shared locally may need to be “reviewed”.

“Doctors will inevitably be on furlough, but I’m still concerned that the systems in place at the time weren’t robust enough to ensure adequate coverage was in place to move forward with urgent cases,” she said.

She called on Bourne Leisure (of which Butlins is a part) to develop a national system for managing health and safety at its sites.

The Argus: Butlins in BognorButlins in Bognor

She expressed “deep concern” about whether a “sufficiently robust” system for investigating and reporting incidents was in place so that “lessons could be learned” and then shared with staff.

Ms Harrison was also concerned about evidence that many months after the incident, the installation of an outside telephone line and sufficiently automated external defibrillators in key areas such as restaurants and swimming pools had not been completed.

And she said witnesses during the investigation confirmed there was no written standard operating procedure outlining how personnel can get first aid assistance quickly and when and how to call 999, especially if a trained first responder is not prompt is available .

She concluded in her report that action should be taken to prevent future deaths. Action should be taken after a toddler died by choking at Butlins in Bognor

Fry Electronics Team

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