A four-year-old boy with cerebral palsy has died after he got his head stuck in his medical bed, an inquest has heard.
Ethan Wade was discovered by his father at their home the following morning in July 2022 face down, unresponsive and ‘floppy’.
The youngster had spent the first night in his new special cot before he passed away.
The specialist Olaf bed was installed at the home in Chatham, Kent due to Ethan having cerebral palsy.
He was also non-verbal and suffered reflux and global development delay as well as mobility issues.
Both parents said Ethan’s bed was left at its lowest level, as recommended, when he was put to bed the night before.
Ethan’s death was recorded as a lack of oxygen and blood flow to the brain.
Paying tribute to her son, Jessica Gardiner said: ‘Ethan was the light and soul of our lives. He was such a happy-go-lucky boy, always had a smile on his face that made you smile.
Ethan Wade was discovered by his father at their home the following morning in July 2022 after the youngster had spent the first night in his new special cot
‘He was such a larger-than-life character. Ethan is forever loved, cherished and adored by myself, his dad, brothers, sisters and all who knew him.’
‘When Ethan roared with laughter no one could resist laughing along with him, his laugh was so contagious.’
On 1 July 2022, Mr Wade pulled him free and alerted Ethan’s mother, Ms Gardiner, who dialled 999 before administering CPR as instructed by the ambulance operator.
Paramedics took over, ‘scooping’ him to their van where they continued resuscitation with help from a critical care worker for about 25 minutes.
After a heartbeat was detected, he was taken to Medway Maritime Hospital accompanied by his mum.
He was transferred to King’s College Hospital in London later on that day where his condition deteriorated and he died four days later.
Dr Virginia Fitzpatrick-Swallow, a Home Office forensic pathologist, recorded the cause of death as hypoxia, a lack of oxygen and blood flow to the brain and consistent with entrapment.
She noted the nose and mouth had been covered resulting in a ‘degree of smothering’.
Red ladder stripe marks on his neck and collarbone could have been caused by the ‘puckering’ of the mattress.
Dr Fitzpatrick-Swallow said on a video call to the inquest: ‘There was no underlying independent, natural disease that would explain respiratory arrest.’
After raising the alarm at around 8am, a uniformed police officer arrived at the three-bed specially-adapted terrace on Newham Street wearing body-worn video to record his visit and conversations with the parents.
In one clip Mr Wade is heard to say that Ethan’s younger sibling, with whom he shared the box room, had been known to ‘play’ with buttons which, on cross-examination by counsel, he ‘did not recall’ saying.
The bedroom was sealed off from public use and hours later a detective inspector and forensic officer attended to take pictures and examine the scene.
No evidence of criminality was found and the police agreed to Mr Wade’s request to remove the bed the following day.
On July 8, it was inspected at the warehouse of Medequip, which supplies equipment on behalf of Medway Council and NHS Kent and Medway, by representatives from Theraposture and an occupational therapist manager at Medway Community Healthcare.
Ethan’s death was recorded as a lack of oxygen and blood flow to the brain
No defects were found and the matter was referred to the Health and Safety Executive and the Medicines and Healthcare Regulatory Agency.
The bed was delivered and installed by Theraposture which specialises in tailor-made, adaptable furniture.
Sam Tucker, who was a driver and trained installer, took away the old bed and put up the new one, carried out a risk assessment of the property, did the usual safety checks, gave a demonstration of functions and offered advice.
He did the handover with Mr Wade and said he seemed ‘competent’ as he was already familiar with the Hannah bed, which Ethan had temporarily used after breaking his cot.
The Hannah cot had fitted padding and a mechanism handset with a key that they kept on the top of a wardrobe in another room – out of reach of other children.
The remote for the newly-delivered Olaf was hung over the top of the rail and neither Mr Wade nor Ms Gardiner could recall seeing the key.
Giving his evidence on video, Mr Tucker said Mr Wade raised no concerns, issues or questions.
He said on her return Ms Gardiner signed the paperwork which he placed in a folder and sent off to his employees.
However, during their evidence, Mr Wade and Ms Gardiner said they were concerned with Velcro strips on the bed as Ethan had a habit of stripping off the same fabric used on his leg splints.
They also claimed they were promised a new bed, but this one was 10 years old, dirty and had Paw Patrol stickers on it.
They also said Mr Tucker did not leave behind a user manual or a copy of the completed checklist when he left the house.
Mr Tucker has since left the company for ‘completely unrelated reasons’ and his boss David Holton gave evidence praising his work with the firm and his capability.
Mr Holton, chairman of the board of directors and co-owner of Theraposture, told the jury that his company had a contract with well-respected German company KayserBetten which abided by stringent EU directives and independent testing.
In the 20 years he had been dealing with the Olaf bed it had never been subject to a recall.
Also giving evidence was Det Insp Sulling Chan who went to the home address on the morning of the accident and Medway Maritime Hospital.
After being briefed by an officer and taking into account the body video coverage, she examined the room and bed looking for any other evidence.
Regarding the handset, she said: ‘I recall seeing a chain, but not a key. But then at the time I wasn’t looking for a key, it wasn’t an issue.’
Assured that a crime had not been committed and no third party was involved, she came away with three hypotheses including mechanical error, natural causes, or user error – the first two had been ruled out.
She told the court: ‘There was no evidence for an alternative explanation.’
While Det Insp Chan was not at the first bed inspection in July 2021, she was present at the second re-inspection on July 17, 2023, along with Mr Wade and Ms Gardiner and legal representatives from Theraposture, Medway Community Healthcare and Medequip.
On that occasion, she could see the key clearly attached to the chain on the remote control and the bed was in good working order.
Ethan and his twin, who died three days after birth, were born prematurely at 27 weeks and suffered several serious medical conditions.
After spending three and a half months in a specialist baby care unit, Ethan was allowed home under the care of physios and occupational therapists employed by Medway Community Healthcare.
At 18 months, after his parents recognised he was not reaching the usual milestones, he was diagnosed with cerebral palsy.
Ethan attended Abbey Court SEN School and Snapdragons, a child development centre, both in Strood.
Joanna Hovenden, an MCH children’s physio, observed Ethan from when he was a baby and described him as ‘inquisitive’ and very speedy with no safety awareness.
She said: ‘He’s best described as a bull in a china shop.’
Ms Hovenden added while he could pull himself up standing he would not have been able to reach the handset.
She said his balance was poor and he would have found it ‘challenging’ to hang on to the rail.
Emma Rayfield, who was his allocated occupational therapist, helped to select specialist equipment for Ethan and chose the Olaf bed after looking at all options because it met his medical needs.
She ordered it online from Rochester-based Medequip.
Ms Rayfield helped his mother apply for the interim Hannah bed which arrived on June 22 after Ethan broke his cot by bouncing on it. She then chased up the new bed for the family.
Normally when a bed has been ordered, she would get an email from Medequip notifying when it is due to be delivered and then a confirmation when the job has been completed.
She would then arrange a home visit to ensure everything was in order.
Ms Rayfield told the inquest that with regard to the Olaf delivery, no such communication was received.
Inquest jurors decided ‘user action’ was to blame and delivered a conclusion of an accident.
After the jury reached its conclusion, assistant coroner Catherine Wood said: ‘My sincere condolences on the absolutely devastating loss of your child.. I can’t imagine how difficult this entire process has been.
‘I am truly sorry for your loss and hope the inquest process has helped answer some of your questions and it’s brought you some closure.’
Ms Gardiner said after the verdict about how Ethan’s condition never held him back.
‘He loved to whizz around on his walker – we called him our little pocket rocket. If you came to visit our house, everyone knew to watch your feet or he would run them over,’ she said.
‘Ethan also loved to hum a tune, despite being non-verbal you got to know them.
‘He loved to visit the park or just a simple trip shopping. Ethan would get so excited, especially if it was food shopping.
‘Ethan loved his food but was very particular when it came to chips. McDonald’s chips or any frozen chips just were not acceptable – he loved nothing more than good old-fashioned homemade chips.
‘He was born against all odds at just 27 weeks and he spent three-and-a-half months in hospital.
‘He was later diagnosed with cerebral palsy and we were told he wouldn’t do half the things he achieved.
‘A true warrior, he learned to roll over, crawl and walk with his walker.’
Family friends Daisy and Lily Campbell said: ‘We will miss Ethan’s cheeky smile whenever you entered the same room as him.
‘His laugh was so infectious and he was determined to never give up – he was such a strong little warrior taken far too soon.
‘We all treasure the memories he left. For a boy so small he achieved so much.
‘Ethan’s memories will forever live on in all who knew our cheeky boy.’