The parents of a toddler who died a day after heart surgery at Bristol Children's Hospital say they still have many unanswered questions.
An inquest heard how Isabella Janew had been given two overdoses by doctors when she suffered a cardiac arrest in September 2013. But a coroner said the cause of death had been due to a congenital heart condition and recorded a narrative conclusion.
This means that the cause of death is recorded without attributing the cause to a named individual.
Here are Isabella's parents speaking after the inquest:
An inquest is expected to conclude today into the death of a 16 month old girl from Gloucester who died after heart surgery at the Bristol Children's Hospital.
The hearing learned yesterday that doctors spent 40 minutes trying to resuscitate Isabella Janu. A consultant at the hospital said there was so much blood coming out of her lungs they couldn't revive her.
An intensive care doctor has told an inquest that Isabella Janew's death was one of the most distressing events of his life.
An inquest heard how doctors spent 40 minutes carrying out CPR on Isabella when she went into cardiac arrest for the second time on 10th September 2013 at Bristol Children's Hospital.
But Dr Peter Davis said when they started chest compressions there was tonnes of blood coming out of her lungs and they struggled to ventilate her.
He said he didn't understand what caused Isabella to go into cardiac arrest.
A nurse has been describing how she sat stroking the hair of a toddler to comfort her moments before her heart stopped beating.
An inquest heard how Isabella Janew's eyes rolled back as she was being comforted by nurse Cheryl Lewis in the Intensive Care Unit at Bristol Children's Hospital.
The nurse said within seconds her heart dropped and she shouted for help. She told the inquest how doctors began chest compressions while she helped with Isabella's breathing. But the 16-month-old never recovered.
The day before Isabella has been admitted for an operation to widen her narrow heart artery. She suffered a cardiac arrest during the operation and was then taken to Intensive Care where she was looked after by nurse Cheryl Lewis.
During the inquest her parents said they had seen their daughter's blood pressure levels fluctuate and drop. They said when they voiced concerns Cheryl Lewis turned the monitor away.
Today the nurse told the inquest that she had turned the screen away to concentrate on Isabella and had called a doctor over when she noticed her low blood pressure, who had given her medication to stabilise it.
But during the inquest the nurse admitted she had never seen signs of an abnormal heart beat on a monitor, something known as an ST depression. But when analysing the print outs from the machine showing Isabella's last half hour, the nurse admitted her heart had at times shown it was in distress but said it was so fleeting she hadn't noticed it on the monitor. She told the inquest that although she had never seen an ST depression in real life she said she felt her training was adequate enough to recognise it.
The inquest continues.
An inquest continues today into the death of a 16 month old girl who died after heart surgery at the Bristol Children's Hospital.
Isabella Janew from Gloucester died after a procedure on her heart that her parents were told was routine.
The hearing learned yesterday that Isabella went into cardiac arrest during the operation and a trainee doctor injected her with ten times the recommended dose of adrenaline. She died the next day.
An inquest has heard how a trainee doctor gave a 16 month old girl a dose of adrenaline ten times the recommended level, and then failed to record it in her notes
Isabella Janew from Gloucester died a day after a heart operation at the Bristol Children's Hospital - her parents say they raised concerns about the drop in their daughter's blood pressure but were ignored by medical staff.
Victoria Davis reports from Avon Coroner's Court.
The inquest continues.
The inquest into the death of 16-month-old Isabella Janew has heard how a trainee doctor gave her a dose of adrenaline ten times the recommended level and then failed to record it in her notes.
Isabella died a day after a heart operation at the Bristol Children's Hospital - her parents say they raised concerns about the drop in their daughter's blood pressure but were ignored by medical staff.
The parents of a 16-month-old girl have told an inquest how they raised concerns about the drop in their daughter's blood pressure but were ignored by medical staff at Bristol Children's Hospital.
Isabella Janew died a day after a heart operation. Her parents, who live in Gloucester, say they witnessed her blood pressure fluctuate and drop an hour before her death. The inquest continues.
The inquest is due to be held into the death of a 16 month old girl who died after heart surgery at the Bristol Children's Hospital.
Isabella Janew from Gloucester died after a procedure on her heart that her parents were told was routine. It's the 8th inquest into child cardiac deaths at the hospital.
The coroner has recorded a narrative verdict at the inquest into the death of a four-month-old baby from Bristol.
Lacey-Marie Poton's mother Emma Norley said she believes more could have been done to save her daughter, and that changes need to be made.
Lacey-Marie was born with a complex heart condition and died in July 2013 after surgery at the Bristol Children's Hospital. In an emotional account of the events, Emma Norley told the hearing she thought her child was too sick to be sent home.
I am happy with the verdict but I'd like changes with the ambulance services and the hospital, because I don't want this happening to another child.
The hospital has responded to the verdict, reiterating that Lacey-Marie's condition was thoroughly assessed before she was discharged from hospital.
The coroner’s independent conclusion is that the cause of Lacey-Marie's subsequent sudden deterioration is unknown but she made no criticisms of the care Lacey-Marie received at the Bristol Children’s Hospital. We would like to reiterate our deepest condolences to her family.
The ambulance service also responded, apologising for where the standards had fallen short.
South Western Ambulance Service NHS Foundation Trust accepts the verdict given by the coroner. All of our clinicians strive to deliver the best possible care, with the patient and their family’s interests at the heart of everything they do. The Trust is very sorry that some elements of the care did not meet the high standards expected.
The Trust fully investigated the care given to Lacey and Ms Norley accepted the Trust’s apology and was satisfied with the remedial action that was taken in respect of this incident.