Friday

Early hours

There were some indications that this is when Mark’s bowel ruptured, which would be one explanation for his excruciating abdominal pain.

A nurse bleeped a doctor twice but nobody came.

08:00

Janet joined her husband back at their son’s bedside. She was appalled by Mark’s weakened state and obvious deterioration. She says he was very pale, tired and in excruciating pain.

A new nurse started her shift and recorded Mark as having an alarming high score on the EWS. She immediately called for help.

She contacted the Critical Care Outreach Team, who said they would see Mark, but they were called away to another patient. Mark would never be assessed by them.

Mark’s parents say a doctor asked to see his fluid charts and described him as dehydrated. They say he remarked on the fact that Mark had only been given a maintenance dose of fluid.

Mark needed a higher fluid intake than the normal maintenance dose, to make up for days of fluid loss. The doctor immediately prescribed extra fluids and the first intravenous liquid nutrition of Mark’s five day stay in hospital.

Just how much fluid he was then given has become of great significance.

Mark's last hours

Mark’s parents say staff pumped more and more fluid into him.

At one point he sat on the side of the bed in “absolute agony”. Janet says she asked him if he was struggling to breathe. Her son replied that he was, and he wondered if this would mean his operation would be brought forward.

His mother says she could hear a strange, crackling noise in his lungs when he breathed.

She rushed out to speak to a junior doctor. She claims that doctor described Mark as having mottled skin and cold hands.

It’s significant because it would indicate that Mark’s body was shutting down. The 2018 report into his death later concluded that it was unlikely that Mark’s skin was mottled.

The junior doctor told the family that the crackling sound was the fluid going into Mark’s lungs. Since Mark’s death, that doctor has said she may have been wrong about this and the report has supported this.

After months of research, however, the family believes the doctor had correctly spotted a condition called “fluid overload” and that Mark had been “drowning”.

An earlier version of the report suggested that in the final five hours of Mark’s life he was given more than seven litres of fluid, that’s more than double the dose that many medical experts would recommend in such a short space of time. But that was adjusted down to four litres in the latest version of the report.

Richard describes how his son’s face and body visibly swelled up. “They were just pumping it through and we could see Mark getting bigger,” he says.

Some of the doctors involved have defended this rapid rehydration as an attempt to save Mark’s life through what’s known as fluid resuscitation. The report concluded that Mark had needed “aggressive fluid resuscitation” and that it would have been “negligent” not to do so. It states that did not affect his outcome.

By 10:30

Mark had been seen by five doctors, but it would be at least another two hours before the true extent of his deterioration was recognised by senior staff.

12:30

A phone call came through to say Mark’s operation would be delayed by at least an hour.

13:35

Another doctor came to do pre-op checks on Mark and realised that he was “critically unwell”. He was pale, clammy and breathing quickly.

Within minutes, Mark was being wheeled towards the operating theatre.

His parents say their son lifted off the oxygen mask and asked: “Nothing terrible’s going to happen is it? I’m not going to die?”

Richard answered: “Of course you’re not going to die Mark, it’s not allowed on this ward.”

The lift was only a short distance away. His parents asked if they could go with him but they were told to take the stairs.

“He was terrified,” says Janet.

“We’d always gone in the lift with him before,” says Richard. “The lift doors were just closing and he looked at me absolutely terrified and that’s the last time I saw him alive.”

Mark was taken into a room next to the operating theatre where more fluids were rapidly put into his body. An anaesthetic was then administered.

Approximately two minutes later, Mark had a cardiac arrest.

Staff tried to resuscitate him for 45 minutes.

CPR was still being carried out when Richard and Janet entered the room. They had been desperate to be with Mark.

14:53

Mark was pronounced dead.

His parents held their son’s hand.

Janet said she just felt numb and Richard, who was very distressed, simply said: “I’m sorry Mark.”