Coroner has ‘no doubt’ diagnosis could have prevented death of baby boy

A coroner has said there were “missed opportunities” from “many” medical visits which could have saved the life of a one-year-old boy.

Archie Squire died from heart failure in the early hours of November 23 2023, after successive cardiac arrests, days after his first birthday.

He was suffering from a rare heart defect in which the heart’s lower half is reversed, which was never diagnosed despite at least 16 visits to medical staff in his 368 days of life.

On Friday, the inquest at Kent and Medway Coroner’s Court in Maidstone, heard that if Archie had been diagnosed earlier he would “almost certainly not have died at the time he did”.

Area coroner Sarah Clarke said: “I have no doubt earlier recognition and diagnosis of a very rare heart condition would have made a difference to the outcome for Archie.

“There are many points in the chronology where there were missed opportunities to do something differently to make the diagnosis of Archie’s condition more likely.”

Archie’s parents made repeated visits to Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate, Kent, and to St James’ Surgery in Dover, with concerns about Archie’s breathing and constipation which did not lead to long-term diagnoses.

The coroner continued: “He died as a direct result of heart failure with an underlying congenitally corrected transposition of the great arteries – a rare condition that could have been diagnosed by an echocardiogram.

“Despite many presentations to medical personnel in the weeks and months leading up to his death, an echocardiogram was not undertaken.”

His mother, Lauren Parrish, from Dover, recalled her son being labelled a “mystery child” because doctors were not sure what was wrong with him.

“It felt like every time we sought medical help for his breathing he was diagnosed with some form of chest infection,” Ms Parrish said in a statement read by the coroner.

Ms Clarke added that if a diagnosis had been found for Archie “he would almost certainly not have died at the time that he did”.

A report by paediatric cardiac surgeon Professor David Anderson noted an “unacceptable” delay in Archie receiving an echocardiogram after being referred to QEQM by a GP on October 6.

He wrote: “If his diagnosis had been correctly made, he almost certainly would not have died when he did.”

It added that “the delay in obtaining an echo was unacceptable”.

Last week, Ravindra Kumar, a paediatric registrar at QEQM responsible for Archie on the night he died, cried in court describing how his work has changed since Archie’s death.

Asked what he would do differently, Dr Kumar said: “I regret talking about Archie’s condition in front of the family to others, to my colleagues, I learned a big lesson to be more compassionate.”

Medical records and Dr Kumar’s witness statement suggest he did not see Archie between 9.30pm and 1am on the night he died, the inquest heard.

Archie’s godmother Nikki Escudier read a pen portrait of Archie to the court.

She said: “Archie Squire was a shining light. A little boy whose laughter, love and joy touched everyone lucky enough to know him.

“Born on November 20 2022, Archie brought happiness into the world from the very beginning.

“In just 368 precious days, he filled every moment with warmth, laughter and the kind of love that stays with you forever.

“His smile lit up the room and his presence left a lasting mark on every heart he touched.”

The coroner commended Archie’s family on their support for each other throughout the process, and has asked the East Kent Hospitals Trust to provide further evidence of their updated action plans and procedures since Archie’s death.

At the conclusion of the inquest, Tracey Fletcher, chief executive of East Kent Hospitals, said: “We offer our sincere condolences to Archie’s family. We can only imagine the pain they have endured and we are truly sorry that we did not identify Archie’s condition earlier.

“After meeting with Archie’s family, we have made important changes to our service. These include one standard process for triage and booking of child referrals, and prioritising the assessment of children referred to us. We will examine further learnings identified through the inquest process.

“Staff across the trust now receive specialised training to improve how clinical concerns, diagnoses and plans are discussed with families in our care. The training for our children’s health team specifically draws on lessons learned from Archie’s death.”