The Kent North East Area coroner concludes that doctors missed opportunities to identify congenitally corrected transposition of the great arteries in 16 visits to A&E.
At a full inquest, a coroner has concluded that doctors missed opportunities to identify a rare heart condition that caused the death of one-year-old Archie Squire.
As Healthcare Today reported in mid-April, Squire was born in November 2022 with an undiagnosed heart condition. He was reviewed in the A&E and Urgent Care Centre at Queen Elizabeth the Queen Mother (QEQM) hospital in Margate more than ten times over his life with symptoms including constipation, breathlessness and failure to thrive.
The day after his first birthday, Squire was admitted to the hospital from A&E due to constipation and vomiting. He died two days later after suffering two separate cardiac arrests.
Recording a narrative conclusion, Kent North East Area coroner Sarah Clarke said that Squire died from heart failure and congenitally corrected transposition of the great arteries (ccTGA), a rare heart defect in which the heart’s ventricles and great arteries are reversed.
Seen 16 times
Records show that Squire was seen by frontline medical staff no fewer than 16 times across his life, including nine trips to the QEQM accident and emergency department. He was never given an echocardiogram, an ultrasound scan which can diagnose ccTGA.
The coroner concluded that earlier recognition and diagnosis of Archie’s heart condition would almost certainly have meant he would not have died when he did. She is now considering whether to issue a prevention of future deaths report and has given East Kent Hospitals University NHS Foundation Trust two weeks to provide documents, including new standard operating procedures regarding ongoing referrals and triaging.
“In those months, he had been seen on many occasions by various clinicians, while exhibiting signs and symptoms of heart failure, and yet this was never diagnosed. Had it been diagnosed by an echocardiogram, he almost certainly would not have died when he did,” said Lily Hedgman, associate solicitor in the medical negligence department at Leigh Day,
Emily Raynor of Old Square Chambers was instructed as counsel for the family.
The inquest considered evidence from 27 witnesses across eight days at Oakwood House, Maidstone. It began on 19 May and concluded on 30 May.
