Max Warr, 13, suffered a “catastrophic” and “unsurvivable” brain damage as a result of medical personnel’s attempts to resuscitate him.
On March 15, 2020, he passed quite tragically in an incident that coroner Mrs. Rosamund Rhodes-Kemp described as “extremely upsetting” for everyone concerned.
The Winchester Coroner’s Court hearing was informed that Max had previously had a number of medical treatments because he was born with a complicated congenital heart problem, which meant that his heart had not developed properly.
After receiving treatment at Oxford’s John Radcliffe Hospital, Max’s care was moved to Southampton General Hospital, where he had surgery on March 11 to repair a “profoundly deformed” pulmonary valve.
Max was described as “a boy who had the entire world in front of him” by his 57-year-old uncle Robert Kilby. He said, “There were unlimited dreams for him – none of them were realized, which was the tragedy.”
“This procedure would have given me a fresh start.” It would have enhanced his health and provided him with a much better and more promising future.
Mr. Nicola Viola, the lead surgeon, said before the inquest that Max’s risk was “quite modest” and that early indications in the operating room indicated the procedure would be successful.
Max, a student at Wallingford School near his home in Warborough, Oxfordshire, had a heart attack after the treatment and was sent to a pediatric critical care unit.
The inquiry heard that the CPR treatment caused “dramatic” and “rapid” bleeding in his chest among “chaotic” conditions.
The now-retired consultant anesthetist Dr. Gareth Chalton, who cared for Max during his surgery, concurred: “The tragedy is that external massage seems to have caused this hemorrhage.
Because of the drama involved, everyone engaged is experiencing extremely strong emotions. There are many individuals there, and voices are raised, demanding for medications and blood, which is not ideal but it is normal.
“Running smoothly and peacefully in this circumstance is incredibly demanding and challenging.” You can’t possibly do that.
Tragically, Max was left “exsanguinated,” which means that his body was depleted of blood after it collected in his chest, depriving his brain of oxygen for a period of time.
Max was taken off life support after two days.
The catastrophe “damaged [him]self and [his] team profoundly,” Mr. Viola told the court, adding, “This is not at all the conclusion that we were anticipating.”
There were “endless dreams” for Max, none of which were realized, which was the tragedy, according to his uncle Robert Kilby (above), 57, who described him as “a boy who had the entire world in front of him.”
He acknowledged that the evaluation of Max’s condition had not been adequate.
He said, “Max did not get the attention he should have.” “I believed Max’s coronary arteries to be secure.” This evaluation was insufficient. We need to make a difference in this area.
Max’s mother Sarah Kilby, 57, described her son as a “cheeky, hilarious boy” who adored dogs.
We’ll never know what he might be doing now, she said. We mourn him very badly since he was a lovely boy.
“I want to thank every employee who attempted to save Max’s life.” I’m aware it wasn’t simple. I appreciate all of your work.
Max’s death was declared accidental by Hampshire Area Coroner Mrs. Rhodes-Kemp, who noted that despite greatest efforts, individuals might sometimes be “defeated by circumstances.”
2008 saw the tragic death of Max’s father Philip Warr, Sarah’s lover.
Sarah spearheaded a fundraising effort to name and sponsor a medical detective dog in Max’s honor after her son passed away, which brought in £12,500.
To assist pay this “living memorial” to their nephew, Robert and Max’s aunt Carly did a six-peak challenge in Somerset with their dog Dyce.
Max’s pancreas and kidneys were given, saving the lives of two other individuals.