‘Missed opportunities’ contributed to death of one-year-old in QEQM hospital
05:00, 22 July 2024
updated: 12:18, 22 July 2024
The family of a one-year-old who unexpectedly died says the wait for answers and “missed opportunities” has prevented them from grieving.
Lauren Parrish’s beloved Archie Squire was in and out of Margate’s QEQM hospital suffering constipation, breathlessness, sweating and stunted growth, between August and November 2023.
During five hospital visits, medics missed the fact the “happy and always smiling” child suffered an undiagnosed and extremely rare heart condition.
As Archie rapidly deteriorated he was placed in the care of Rainbow Ward on November 21 but suffered a fatal cardiac arrest two days later.
A post-mortem revealed the heart failure was caused by isolated cardiac ventricular inversion, where the left atrium enters the right ventricle and vice-versa.
An East Kent Hospitals Trust investigation into the death, ordered by the coroner, found there were “missed opportunities” to recognise an “abnormal cardiac shadow” on X-ray.
Faults were also found with delays in accepting GP referrals, inconsistent documentation and reviewing of previous clinical papers.
The comprehensive 89-page report prepared ahead of Archie’s inquest also highlights a failure to consider a wider diagnosis beyond bronchiolitis – a condition Archie had been diagnosed with.
Ms Parrish, Archie’s brave mother, told KentOnline the recent findings devastated her.
“The investigation is just so ongoing and demanding, you don't get time to grieve.
“Everything's just constant, meeting after meeting with the hospital and waiting for reports to come back has taken ages,” she said.
“Some families wait for years, it’s too long – it needs to be much quicker.
“My first reaction to the report is they’ve messed up big time, and things happened that we were never even told about.
“Everyone we know is just shocked and devastated at everything that's gone on because you wouldn't think taking your son to hospital for what we did that he wouldn't come back out again.
“But I would say the investigating team that we had were really good, they were quite thorough, they went in detail and found loads of stuff that we weren't even aware of, so I can't fault them at all.”
Archie – who “shut down Margate” at his funeral – was described by mum Lauren and dad Jake Squire, both of Dover, as a “happy little lad who was always smiling”.
An older brother to Albie, the toddler was also “a real daddy’s boy” and was part of a family which spanned five generations.
He was admitted to Rainbow Ward on November 21 due to constipation and vomiting but his condition worsened the following day after receiving treatment via a tube.
Within the space of four hours early on November 23, he entered cardiac arrest twice – with CPR successfully bringing him back once.
However, the second arrest proved to be fatal with Archie’s time of death given as 5.28am.
Between August and November 2023, he was brought to QEQM five times, where his breathing issues were documented as bronchiolitis.
Although it was noted in the report there was a need to “exclude cardiac cause” due to “sudden bouts of sweating and breathlessness after feeds” during an October visit.
However, this was neither requested nor triaged as urgent and was due to take place six to eight weeks after his discharge.
Investigators wrote in their report: “There was a delay in recognising in a timely manner, Archie’s clinical deterioration.
“Archie’s referral was not marked as urgent, however, any GP referrals mentioning faltering growth should be either booked in a rapid access clinic or for an urgent paediatric review, or changed to an urgent referral.
“There is no evidence that this differential list (on clinic letter, EDN and careflow) followed Archie through his subsequent admissions, therefore resulting in missed opportunities to diagnose him appropriately.
“There was also no evidence of a robust follow-up plan in the context of faltering growth nor where the family can seek help if they have further concerns.
“There were inconsistencies in the quality of documentation of reviews, investigation findings and response to treatment given.
“Although we recognise his symptoms of cardiac disease were subtle we believe had a broader differential diagnosis in the context of faltering growth been considered and communicated effectively he would have been investigated further.”
Thirteen recommendations were subsequently made, including to “provide more compassionate care and behaviours training to enhance care received after child deaths”.
While Archie’s pre-inquest review has been provisionally pencilled in for August 1, a date for the full probe is yet to be confirmed.
Sarah Hayes, chief nursing and midwifery officer at the trust, said: “Our hearts go out to Archie’s family and we are so sorry for their devastating loss.
“We will do all we can to support Archie’s family and the coroner’s investigation.”
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