Video report by ITV News Correspondent Damon Green
A grandmother has expressed anger - but no surprise - after an inquest found neglect from a children’s hospital led to the death of her grandson.
Julie Rowlands said she told staff nine times something was wrong while her grandson Kayden Urmston-Bancroft was left waiting days for emergency surgery.
Kayden, aged 20 months, was admitted to the Royal Manchester Children’s Hospital on April 12, 2016 for surgery on a diaphragmatic hernia.
He suffered a cardiac arrest on April 15 and died two days later.
Reacting to the inquest, Ms Rowlands said: "I knew that there could have been a different outcome, if they didn't leave it as long as what they did."
The four-day inquest heard Kayden, from Stockport, had been transferred from Stepping Hill Hospital and placed on a list of patients requiring emergency surgery.
Coroner Angharad Davies found Kayden died of natural causes, contributed to by neglect.
She said the "unacceptable delay" in Kayden’s surgery was "sufficiently serious to amount to a gross failure".
Ms Rowlands said Kayden was a "very bubbly" boy and said even prior to going to the hospital he was full of energy.
"On the morning before he went to the hospital in the afternoon he was running around everywhere, under his bed, chasing his cat, he was a normal little boy that presented no signs of having a hernia, none whatever," she said.
But after the traumatic events at the hospital, she advised other parents: "Don't ever leave a child in hospital alone... Not once were we listened to regarding his care, not once."
The coroner identified there were missed opportunities to perform the surgery and said "a number of serious and basic failings which meant Kayden was not operated on that week".
His medical notes said there was no bed available in the hospital’s high dependency unit (HDU), so he was not able to have the operation.
The notes said his mother Shannon Bancroft was "very upset" at the delay, but recorded that she was told by his consultant that Kayden remained well.
A report compiled after his death showed a bed was not requested for Kayden until midday on April 15 and records showed there had been three beds available that day.
The court heard consultant Mohamed Shoukry had thought the bed for Kayden had been taken by another emergency.
Ms Davies said: "It is inexplicable to me why Mr Shoukry was under the impression there was no HDU bed available on Friday."
She told the court there had also been "confusion" over who the consultant with responsibility for Kayden’s care had been.
In a separate statement, Kayden’s family said: "Kayden’s death has devastated our family, he has left a huge hole that cannot be filled and we miss him every day."
"Time doesn’t make it any easier and knowing that he could have been saved is hard to bear."
They continued: "We begged them to help him over and over, but instead we had to watch him fade away.
"He died in pain and that’s the thing I don’t think we can ever forgive."
"By the end it was clear he was giving up and while it broke our hearts, we had to make the decision to let him go."
Stephen Clarkson, a clinical specialist lawyer, representing the family, added: "This is a highly-respected children’s hospital, but what we have heard is evidence of a disorganised system where certain staff were unaware of procedure and who was in charge."
"What resulted was that no one took accountability for Kayden’s care until, tragically, it was too late," Clarkson added.
Professor Bob Pearson, previously spokesman a NHS Foundation Trust, which runs Royal Manchester Children's Hospital, said: "We offer our sincere condolences to Kayden's family and profound apologies for the lapse in standards which led to his death.
"The trust accepts the findings and conclusions of the coroner.
"As soon as Kayden died, we launched a rigorous and wide ranging investigation to establish what had happened and put in place measures to ensure this does not happen again."