Birmingham coroner Aidan Cotter recorded a narrative verdict to the inquest into the death of Hayley Fullerton.
He identified five failures by Birmingham Children's Hospital in the days leading up to Hayley's death.
- 1. Nobody appears to have recognised it was unusual Hayley still needed oxygen so long after surgery. 2. A chest x-ray was not carried out in a timely manner.3. Physiotherapy to treat a collapsed lung was ordered on November 9th but not administered until 22 hours later.
- 4. Hayley was not referred to the paediatric intensive care unit on November 9th and should have been.5. PEWS (Paediatric Early Warning System) charts on the ward were not completed often enough or accurately.
However, he said that these failings, while serious, were not gross failings and did not amount to neglect.