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

Two-year-old James Manning, who had enlarged tonsils and had suffered 'dozens of choking incidents' prior to his death, choked on the piece of sausage while at Butlin’s in Bognor with his family in June 2018.

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

James suffered a seven-to-eight-minute cardiac arrest causing a hypoxic ischaemic brain injury, caused by a lack of oxygen to the brain.

He was stabilised and taken to Southampton General Hospital where despite treatment in PICU his life support was withdrawn and he died on June 20, 2018, two weeks after the incident.

Read more: Toddler's tragic death at holiday park was accidental - inquest finds

Assistant coroner Karen Harrold ruled in conclusion at James’ inquest in March 2021 that his death was accidental, but that the youngster had been “let down” due to “red flags” being missed in regard to his enlarged tonsils.

James, from Battle, was well-known to his GP and local hospital (Conquest Hospital) as there had been multiple episodes of choking.

"The NHS did let James down as an earlier intervention may have reduced the chances of James choking on June 6, but I cannot conclude that James's life would have been saved by an earlier intervention,” said Ms Harrold during the inquest at Crawley.

And now in a new prevention of future deaths report Ms Harrold raised several concerns to the NHS and Butlin's.

James Manning (Image: Newsquest)

She said GPs and doctors could benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment, also that further guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care and the inclusion of choking in the ENT UK Commissioning Guide for Tonsillectomy.

She also raised concerns about the delay in James being reassessed and referred for further care, particularly after he was referred for a sleep study following concerns about sleep apnoea, which was exacerbated by staff being on leave.

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

“Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases,” she said.

She called on Bourne Leisure (which incorporates Butlins) to develop a national system for managing health and safety across its sites.

Butlins in Bognor (Image: Google)

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

Ms Harrison was also concerned to hear evidence that many months after the incident, installation of an external phone line and sufficient automated external defibrillators in key areas such as restaurants and swimming pool areas had not been completed.

And she said witnesses during the inquest investigation confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999 emergency call, especially if a trained first aider is not immediately available.

A Butlin's spokesman said all the recommendations from the coroner's report had been implemented.

“James's death was a tragedy and our thoughts remain with his family and friends," he said.

"The safety and wellbeing of our guests is always our priority, and we can confirm the recommendations from last year’s report have been implemented.”