wrong of Justin Fisher's anaesthetist Dr. Tomos Huw Morris not to make close checks on him as he lay unconscious in the recovery room.

Operating Room supervisor Ms Catherine Scotland agreed with lawyer Mr. Julian Hall MP that anaesthetists should not just "park'' their patients in the recovery room and forget about them unless called for.

"It should never be like that,'' Ms Scotland testified. "It is good practice for an anaesthetist to check on his previous patients.'' Ms Scotland was testifying on the final day of an inquest which began last month into Justin's death last January after he stopped breathing in the recovery room following a routine tonsillectomy.

The eight jurors are expected to begin deliberating today following Coroner the Wor. Will Francis' summary of the 14 days of evidence.

Jurors have heard testimony from a total of 15 witnesses who included Justin's mother Jennifer and KEMH anaesthetists, surgeons and nurses.

While on the stand Ms Scotland further agreed with Mr. Hall it was "bizarre'' Dr. Morris should say he saw no cause for concern when he glanced over at Justin as he passed through the recovery room at 12.10 p.m.

The jury heard Justin was found ashen and not breathing between 12.10 p.m. and 12.15 p.m.

Even if Dr. Morris did not look closely enough to notice whether Justin was ashen and not breathing, he should have been concerned that it was taking him an abnormally long time to come out of the anaesthesia, she said.

"After some 30 minutes I would expect Dr. Morris -- if he glanced across at Justin and saw he was still asleep and on his side with an oxygen mask on -- would have been alerted to the fact something was wrong,'' she testified.

Dr. Andrew Spence, the anaesthetist in charge of the ICU, testified he pronounced Justin brain dead last January 18.

Justin had been on life support since doctors managed to get his heart beating again after he went into cardio-respiratory arrest on January 11 following the operation.

Dr. Spence said Justin initially responded to treatment for swelling of his brain, however, when attempts were made to wean him off the ventilator his condition deteriorated.

Dr. Spence recalled how he was grabbed by a frantic nurse Diana Simons at about 12.10 p.m. to assist in resuscitating Justin.

He said it was "extremely difficult'' to resuscitate Justin and based on that, he guessed the child had not been breathing for five to ten minutes.

Dr. Spence testified that in his opinion the role of the recovery room was "so recovery room nurses can take responsibility for our patients on our behalf''.

He said he had never had any problems with recovery room nurses in the past and regarded them as being of a "very high standard''.

When Dr. Morris' lawyer Mr. Coles Diel asked if he had increased his vigilance in the recovery room following Justin's death, he replied, "Yes, although my the level of trust in the nurses is the same.'' Dr. Spence said he knew of unexplained deaths associated with anaesthesia in young children.

Asked Hospitals Board lawyer Mr. Barritt, "Even in a fit 18 kilogram young child who goes in for a routine tonsillectomy?'' "Yes, but it is rare,'' Dr. Spence replied. "Incidents are about one in 10,000.'' The final witness pathologist Dr. John Winwick testified Justin's death was "not altogether due to natural causes'' but to excessive accumulation of fluid in the brain and a deficiency in the amount of oxygen getting to the heart -- hypoxia.

Because of the amount of fluid in Justin's brain, Dr. Winwick estimated Justin had lain in the recovery room not been breathing for at least seven minutes.

Resident anaesthetist Dr. Alexandra Scott, who also chided Dr. Morris for merely glancing over at Justin in the recovery room instead of taking a close look, has testified Justin could have stopped breathing for as long as ten minutes before a nurse noticed.

During the inquest jurors heard Justin's nurse in the recovery room, Mrs.

Pearlette Basden, was suspended for a week by hospital management.

The jury heard she left the recovery room unattended to answer the telephone and go to the bathroom, failing to conduct an important 12.10 vital signs check.

Mrs. Basden admitted she was partially to blame for Justin's death, but said Dr. Morris did not give her enough information on his condition during surgery when he handed him over to her. He also did not make proper checks on Justin in the recovery room, she said.

The jury has also heard the "higher end'' of the recommended anaesthetic dosage was given to Justin by Dr. Morris because he was thought to be hyperactive.

It has been suggested by three doctors that Justin may have stopped breathing as a result of his head slipping forward and his tongue sliding back and obstructing his airway.