The death of a teenager who went into the John Radcliffe Hospital for a spinal surgery would not have died if “appropriate care” was taken, a coroner has ruled.
The sudden death of Zak Fairhurst, 18, came last February after being moved to an adult ward following his surgery, an inquest held at Oxford Coroner's Court heard this week.
After his surgery, he was admitted to Neuro intensive care unit (ICU) and stepped down to the Neurosciences Ward the following day, due to there being no paediatric beds available.
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The court heard how he should have been monitored every four hours after he had been given high doses of morphine but he was not properly checked between 10pm and 6.50am.
Coroner Darren Salter said that Zak, from Corby in Northamptonshire, could have survived if hourly observations had been carried out by nurses.
It was ruled that his death was caused by a cardiac arrest most likely the result of the large cumulative doses of morphine he received.
Mr Salter said: “With appropriate care, Zak would not have died when he did and his death was contributed to therefore by neglect.”
Dr Elaine Hill, acting chief medical officer at Oxford University Hospitals NHS Foundation Trust, said: “We are very sorry for the sad outcome following care at our Trust, and offer our deepest condolences to the family and loved ones at this very difficult time.
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“While we are unable to publicly discuss the care of an individual patient, we have conducted a thorough internal investigation and this has been shared with the family and the coroner.
“As a result of the investigation report we have implemented improvements, including the provision of clearer education and guidance for staff caring for young people transitioning into adult services, including those with learning disabilities.”
His family have since paid tribute to Zak calling him a "perfect bundle of joy".
When he was 18 months, the youngster contracted meningitis and was left with quadriplegic cerebral palsy, epilepsy, global development delay and scoliosis.
He was fed via a tube into his stomach and was non-verbal but communicated through gestures and sounds, the court was told.
Victoria Fairhurst, Zak’s mother, said: “I had lost the Zak I knew, but I got him back in only the way he knew by giving you beautiful cuddles plenty of kisses and great big belly laughs when you made a fool of yourself.
“He had a fantastic sense of humour, and his smile would melt everyone he met.”
James Fairhurst, Zak’s Father, said: “Zak was full of life, he was a bright star, he was bigger than life, he was the life and soul of the party, and he had the best cuddle in the whole world. I love Zak to the moon and back.
“I want to tell the world how Zak was brilliant he was. I miss my son every minute of every day which makes it hard to get out of bed most days."
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