A coroner has penned a report to Medway health bosses highlighting an "oversight" by medical staff which contributed to the death of a nine-year-old boy.

Luke Jackson was not given the right medication at Medway Maritime Hospital to lower the risk of cardiac arrest, an inquest was told.

Now Sonia Hayes, Mid Kent and Medway assistant coroner, has written to Medway NHS Foundation Trust outlining her concerns in a bid to prevent a similar tragedy.

Ms Hayes said Luke's cardiac arrest in December 2019 would have been "avoidable" had he been given medication to raise his potassium level. Failing to do so increased his heart rate which led to a prolonged cardiac arrest.

At an inquest in October 2020, Dr Richard Patey, a paediatric consultant at the Medway hospital, said it had been planned to give Luke more potassium to stop his depleting levels. However, for some reason this request was not carried out, something which Dr Patey admitted was an oversight.

In her report to the trust's chief executive James Devine, Ms Hayes said: "In my opinion there is a risk that future deaths could occur unless action is taken."

Luke, who suffered from Becker muscular dystrophy which affects voluntary muscles, was admitted to the hospital on December 4, 2019 after suffering with diarrhoea, vomiting and a cough days beforehand.

After he went into cardiac arrest two days later, the Medway team performed CPR before deciding to send him to the intensive care unit at Evelina Children's Hospital in London.

His parents, Becky and Adam, were informed he would not wake from his condition and the decision was made to put him into palliative care. He died just under a week later.

At the October inquest, Ms Hayes recorded a narrative verdict, outlining how a lack of communication among the hospital staff and poor management of his condition led to his death.

She made a Section 28 ruling, stating that she would be writing a report to the hospital in an attempt to prevent similar deaths in the future, which she has now done.

Her thoughts were echoed by Luke's father, Adam, who said after seeing her findings: "If anything can stop this happening again, it has to be welcomed."

After the inquest, mum Becky described her son, who went to Abbey Court Special School in Strood, as "a cheeky little boy with a wicked sense of humour".

She added: "He had a big personality that has left a huge void to all those that knew and loved him. He will be greatly missed. The family would like to thank all who helped with his care."

The Medway NHS Trust has to respond to the report by Monday, April 19.

A copy has also gone to Health Secretary Matt Hancock and the Royal College of General Practitioners.

Dr David Sulch, medical director at Medway NHS Foundation Trust, said: “This is a very sad case and I extend my deepest and most sincere condolences to Luke’s parents, both personally and on behalf of the Trust.

“Following Luke’s death, the Trust conducted a full investigation into the issues relating to his care, and we have developed and put in place changes to the way that we work in our paediatric department to minimise the risk of this kind of incident happening again.

“We will be considering the letter from the coroner, and will be responding to her in due course.”

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