Death of two-year-old who choked at Butlin’s in Bognor Regis was accidental, inquest finds
The death of a two-year-old boy who died after choking on a piece of sausage at Butlin’s in Bognor Regis was accidental, a coroner has found.
James Manning, described as a ‘much cherished little boy’, had been enjoying a holiday at the resort with his mother and grandmother when he began choking at breakfast on June 6, 2018, an inquest at Crawley Coroner’s Court heard.
Assistant coroner Karen Harrold said that earlier intervention by paramedics that day would not have saved his life.
Guests were already administering first aid and CPR to James at the Ocean Drive restaurant when paramedics arrived at the scene, having abandoned their vehicle after their path was blocked by bollards.
They found James a ‘deep blue’ or purple in colour, which indicated that he had been without oxygen for ‘a significant amount of time’.
It took them between seven and eight minutes to remove the sausage piece from his throat, where it had been ‘firmly wedged’.
They had to use a laryngoscope to do so, as Ms Harrold said no amount of back blows, Heimlich manoeuvres or abdominal thrusts would have cleared the obstruction.
James was taken to hospital where, despite extensive treatment, life support therapy was withdrawn on June 20.
The inquest heard that James, who had a history of choking and breathing difficulties and enlarged tonsils, had been on a list for surgery to get his tonsils removed.
Ms Harrold said there had been ‘some delays’ to this process.
She said: “The NHS did let James down as an earlier intervention might have reduced the chance of him choking on June 6, but I cannot conclude that James’ life would have been saved with an earlier intervention.”
After he was diagnosed with Severe Obstructive Sleep Apnoa following a sleep study, James should have been on an urgent pathway to surgery, she said.
But she said the doctor at Conquest Hospital was following the agreed pathway by arranging a meeting with James’ family to discuss the study results before referring him to the centre in Brighton for surgery.
Addressing James’ family, Ms Harrold said: “I’m really sorry that the family lost James in this way.
“It must have been a terrible incident to end what should have been enjoyable holiday.
“James was clearly a much cherished little boy.”
She said she would be writing to various organisations, including to the NHS to highlight that national guidance was needed to achieve consistency when referring children for tonsillectomy.
Ms Harrold also said she would ask Butlins to develop to a national system for managing health and safety issues which included sharing information across all its sites.