A grieving mother says she still has unanswered questions about the tragic death of her four-year-old son.

Harry Broughton died at Medway Hospital after he went into cardiac arrest due to his airways being blocked by a mucus plug.

But his parents have been left with questions about his care after there was a delay in the emergency alarm being pulled when he started to go blue.

His inquest in Maidstone heard how his mum, Nicola, rushed him to A&E early on Monday, April 18, 2022, after he had been vomiting and had breathing difficulties.

He was treated and discharged but the family returned when his breathing didn't improve.

The West Minster Primary school pupil was prescribed antibiotics at around 6pm but staff planned to let him sleep and administer them later - a decision criticised by the family and independent reviewer.

At 9.45pm, Harry showed signs of respiratory distress and efforts were made to insert a cannula for further treatment.

Erin Gardiner, a trainee nurse who was on one of her first shifts in the ward that night, said: “I was holding Harry’s hand whilst Dr Elizabeth Ajayi was putting the tourniquet on.

“His mum started to scream saying ‘he’s going blue’.

“The registrar said that it was because of the tourniquet, and took it off. His mum was crying and screaming.

“The registrar was not in the room when I looked up, which was a concern.”

Dr Ajayi said: “Harry started vomiting as soon as the tourniquet was applied at about 10.10pm. He then went into more severe respiratory distress and I initially shouted for an adrenalin nebulizers. Then he stopped breathing and I shouted for help."

Harry had gone into cardiac arrest and they began resuscitation.

Dr Ajayi said she did not pull the emergency buzzer as soon as Harry showed signs of respiratory distress because it was obstructed and quicker to shout for the nurse who was just outside.

Nurse Alison Middleton said Dr Ajayi did not make it clear that an emergency was underway when she called for her.

Ms Middleton said: "I was at the desk when she called and intended to finish what I was doing as I was unaware that this was urgent.

“The registrar then came out and asked for a nebuliser again but added ‘he’s not breathing’.”

Ms Middleton pulled the emergency buzzer.

When they tried to intubate him they discovered a mucus plug which had to be removed by forceps to clear his airway.

Harry had to be resuscitated for half an hour before his heartbeat returned. He was transferred to Evelina Children's Hospital but he had suffered irreversible brain damage and care was ended three days later.

At the inquest, Harry’s parents wanted to know how the delay in pressing the emergency button affected the outcome.

The independent expert on the case, Dr Ross Russell, said the delay wouldn’t have made a difference in Harry’s case due to the mucus plug.

He said: “Being unable to intubate is what led to the extraordinary brain injury Harry suffered. A mucus plug in a child this age is exceptionally rare.

“I’ve only seen three incidents like this in my career and none of those were mucus plugs.”

A pathologist confirmed his cause of death was a brain injury caused by a decrease in oxygen or blood flow that happened because of the large mucus plug obstructing the upper airway, which was caused by an infection.

A serious incident investigation was launched by the Medway NHS Trust following Harry’s death.

Following Harry's death, Robin Edwards, consultant obstetrician and gynaecologist and divisional patient safety lead for planned care division, said: “Staff were well below the minimum training requirements.”

In his report, he explained that lessons to be learnt from the trust included “recognition of, and response to, deterioration, administration of antibiotics in a timely fashion, escalation for consultant review and opinion and initial respiratory arrest - recognition and management” amongst other things.

Coroner Catherine Wood concluded: “The Trust has taken Harry’s death seriously and has put things in place following his death.

“My conclusion is a narrative conclusion. He died as a consequence of a mucus plug obstructing his airway after getting Influenza A on the back of vocal palsy.

“I offer my sincere condolences to Harry’s family and hope you can now try to take steps to rebuild your life.”

After the inquest, Nicola said: “It doesn’t feel like there was a conclusion at all.

“The coroner said she hopes all our questions have been answered but they haven’t.

“What if that same thing happens to a child that would have got better if they were given medication sooner or the emergency buzzer was pulled quicker.”

Alison Davis, chief medical officer for Medway NHS Foundation Trust, said: “This was a sudden and unexpected death and the Trust and all those involved in Harry’s care wish to express their sincere condolences to his family on their tragic loss.

“The Trust carried out a thorough internal investigation into the circumstances leading to Harry’s death and the Coroner’s findings will be carefully considered to ensure all lessons identified arising from these events are embedded for the benefit and care of all children attending the hospital with similar symptoms.”