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A 14-year-old boy died after suffering brain damage following an asthma attack.
Dylan Traynor was found unresponsive at his home in Newcomen Road, Sheerness, by his mum and younger brother on December 6, 2022.
Although he was stabilised at Medway Maritime Hospital, he died at King’s College Hospital in London three days later after suffering permanent brain damage as a result of the sudden attack.
An inquest on Friday into the youngster’s death heard how he was forced to spend time at Medway hospital five months before he died, and how an ambulance arriving at the 999 call within two minutes was unable to save his life.
When found in his bedroom on the day of his collapse, his younger brother informed his mum Traci, that Dylan was acting weirdly and was discovered slumped on the floor, not breathing and with blue lips.
Earlier in the day, he had been given a migraine patch after complaining of a headache – something which could have been a sign of a slow-onset attack.
Although ambulance crews arrived within two minutes of receiving the call for help, they were unable to prevent brain damage.
It is not known how long he was unconscious before CPR was started.
Diagnosed with asthma at the age of six, Dylan was taken to the hospital in July 2022 after a week-long stint of shortness of breath and repetitive coughing fits.
The teen, who was homeschooled in his final days as his condition worsened, was described as being terrified of the hospital out of fear of catching Covid.
Admitting doctor and consultant paediatrician, Dr Richard Patey, informed the court – held at Oakwood Park in Maidstone – Dylan’s asthma was “unpredictable” and was not allergy-related, making it harder to tackle as triggers are less obvious.
He was treated and sent home within a few days, with plans to wean him off the strong drugs he had been taking while in hospital.
But it was later heard how mix-ups in communication and understanding, described as“misguided reasons” by the coroner, led to missed chances for medical professionals to see Dylan before he died.
A routine follow-up outpatient appointment for the youngster at Sheppey Community Hospital on November 25 was cancelled over confusion as to whether he was allowed to use public transport.
Ms Traynor stated the NHS helpline previously told her not to use public transport when discussing bringing Dylan into A&E, both Dr Patey and Dylan’s GP Dr Joyanta Sahu, of the OM Medical Centre in Sheerness, stated they felt this would have been unnecessary at this time.
The rearranged date offered was January 15, which would still have been within the target time to see a previously admitted patient with asthma.
Dr Patey admitted one cancelled appointment wouldn’t immediately be concerning to him and it would only be if Dylan missed the rearranged one that alarm bells may ring.
He said: “Even if an appointment is attended, that doesn't mean to say that all concerns can necessarily go away.
“When somebody is not brought in, there’s no opportunity to check how they are.
“In hindsight, the right medicine available at the right time and supervision and support for him was not there so the emergency treatment plan was unclear and was not able to be followed successfully.”
In the post-mortem, it was found the youngster had no other obvious health conditions although it was noted he had a low BMI and was short for his age.
The use of a home nebuliser – a device which delivers high doses of drugs quickly – was also discussed, with the coroner stating there was “a reliance on having that as a backup rather than on seeking secondary treatment when matters changed”.
First used in March 2022 after Traci bought it privately for Dylan, medical professionals admitted this was not routine and Dr Patey was not aware of Dylan’s use of a nebuliser at home while under his care at the hospital.
However, it was accepted it was not hazardous in this case by coroner Catherine Wood.
Although pushed by NHS representatives to accept the cause of death as natural causes, the coroner offered a narrative conclusion.
The coroner said: “I accept the proposed cause of death as 1A, hypoxic-ischemic brain injury as a consequence of 1B, out-of-hospital cardiovasculatory arrest as a consequence of 1C, exacerbation of asthma.”
Expressing her condolences, Mrs Wood added: “It is not the right order in life to lose a child.”
Sarah Vaux is interim chief nurse at Medway NHS Foundation Trust. She said: “We offer our deepest condolences to Dylan’s parents and family following his tragic death.
“Dylan received the appropriate treatment from our staff. We also acknowledge the findings of the coroner, which were not critical of the care provided to Dylan by the trust.’’
Dylan was a pupil at Oasis Academy until 2021. A spokesperson said: “'We were saddened to learn about the passing of our former student, Dylan.
“As a member of our academy community, our thoughts and prayers remain with his family and friends.”