Magistrates' Court yesterday, with fingers pointing in several directions at the same time.

Justin died in January last year, after suffering cardio-pulmonary arrest in the recovery room after an apparently routine tonsillectomy.

As the inquest went into its 12th day, the assistant unit coordinator of the hospital's recovery room said both she and the hospital's management system bore some responsibility.

She also said Justin's anaesthetist Dr. Tomos Huw Morris did not check his patients as often as he should.

The assistant unit coordinator, Mrs. Doris Rawlins Matthews, at first put the blame squarely in the lap of nurse Mrs. Pearlette Basden, who she said was "completely wrong'' to leave the boy unattended.

But under questioning yesterday morning from the Fisher family's lawyer Mr.

Julian Hall MP, Mrs. Rawlins Matthews agreed she should have noticed a potential problem about 15 minutes before the young boy went into cardio-pulmonary arrest.

That was when she scanned patient charts to prepare for her midday briefing to the incoming shift.

Justin's chart showed the boy had been in the recovery room about 35 minutes without regaining consciousness. It normally takes 10 to 20 minutes to regain consciousness after a tonsillectomy, Mrs. Rawlins Matthews agreed.

Mrs. Rawlins Matthews was not the nurse immediately responsible for Justin's care, but agreed she could and should have worked out the times on the chart.

If she had, she said, she would tried to rouse him. If that failed, she said, she would have summoned the anaesthetist.

While never excusing Mrs. Basden's role, Mrs. Rawlins Matthews also agreed the hospital's management system bore responsibility in Justin's death by providing too few staff.

As a result, she said, she was performing the duties of a recovery room nurse in one area while supposedly supervising the entire unit.

It was impossible to properly do the two jobs simultaneously, she said. She had to leave her own patients, who were all awake and sitting up at the time, to give her report to incoming staff. And she was unable to go between the unit's modules and monitor other patients and nurses.

Under questioning from Hospitals' Board lawyer Mr. John Barritt, Mrs. Rawlins Matthews also had criticism for Justin's anaesthetist Dr. Morris.

Anaesthetists should periodically check their patients in the recovery room, she said. "Some do it all the time, and some do it some of the time,'' she said. But Dr. Morris, she said, "does it occasionally....It should be done more frequently than he does it.'' Near the end of yesterday's session, resident anaesthetist Dr. Alexandra Scott described how she was bringing a patient into the recovery room when nurses discovered Justin was not breathing and called for help.

From his appearance, Dr. Scott estimated Justin had not been breathing for at least three to five minutes. Resuscitation efforts began immediately but Dr.

Scott said it probably took between five and ten minutes before his heart began to beat.

Dr. Scott, who was not the anaesthetist who worked on Justin's operation, said the time taken to recover from anaesthesia varies among patients. Patients are kept under relatively deep anaesthesia for tonsillectomies, she said, to prevent gagging reflexes in the sensitive throat area.

But 35 minutes was an "excessively long time'' to recover from the anaesthesia, she said.