A young couple whose little boy died at QEQM Hospital in Margate just three days after his first birthday say they have been devastated to learn of ‘missed opportunities’ to correctly diagnose him that might have saved his life.
Lauren Parrish and Jake Squire say they were shocked to read the findings of an incident investigation report into the death of son Archie who passed away on November 23 last year.
The couple took son Archie to hospital numerous times since his birth with fears over his health but Lauren says they felt no-one was listening to them.
Between 15 August 2023 and 5 October 2023, Archie was brought to Queen Elizabeth Queen Mother (QEQM) Hospital in Margate on three occasions with concerns about constipation, poor weight gain and troubled breathing.
The cause was deemed to be bronchiolitis and the report says other diagnoses were not explored.
On October 5 Archie was seen at QEQM for an outpatient appointment after being referred by his doctor due to faltering growth and constipation. He was admitted to Rainbow Ward and at that time booked for an Echocardiogram (heart scan) but it wasn’t flagged as urgent and was set for 6-8 weeks’ time. Sadly, Archie didn’t get the chance to undergo the scan.
He was admitted to Rainbow Ward again on November 21 due to constipation and vomiting. Treatment for constipation via a Nasogastric Tube (NGT) was started but Arche’s condition worsened the following day and he was having breathing troubles which were again documented as bronchiolitis.
Archie went into cardiac arrest on 23 November 2023 at approximately 1:40am with CPR successfully bringing him back at 2:48am. But Archie went back into cardiac arrest at 4:19am and sadly died at 5:28am.
A post-mortem found the heart failure was caused by a heart defect called Isolated Cardiac Ventricular Inversion, which means the the left atrium enters the right ventricle and the right atrium enters the left ventricle.
The defect had not been picked up despite X-Rays completed in October showing an abnormal cardiac shadow. Sadly, this was not acted upon.
The East Kent Hospitals’ incident investigation report into the potentially avoidable death of Archie highlights:
- Faltering Growth was not accepted as an urgent referral from the GP.
- An ECHO (a scan used to look at the heart) was ordered in October but was not requested as urgent. It was subsequently not triaged as urgent; Archie had still not received the ECHO when he sadly died in November.
- Clinic letters and previous attendances and admissions were not reviewed when Archie attended Pediatric services or was admitted to the ward.
- X-Rays completed in October showed an abnormal cardiac shadow which was not acted upon.
- Medical jargon was used to explain that cardiac abnormalities were being looked into, which was not understood by the family.
- There was no communication used by the medical team to check the family understood.
- Medical information was not always appropriately shared.
- Archie was treated for bronchiolitis and a wider list of possible different diagnoses were not considered.
- Nursing team not completing observations as per the escalation message
- Archie was not deemed ‘a watcher- to be regularly checked and monitored- even though he met two of the criteria on the watcher list.
- Documentation of clinical reviews were not completed in a timely manner.
- Radiologists not being able to report on Paediatric X-rays caused a delay in imaging being reported on and this was then not detailed enough
- It was noted that Archie’s parents felt that after their son’s death, there was a lack of compassion and post death information sharing was factual rather than caring.
Lauren, who is returning to live in Thanet with Jake and their eight month old son Albie next month, said: “It had been going on since Archie was born but it just seemed every time we went to hospital no-one took notice of what we were saying.
“On October 5th there was a missed opportunity with the heart scan, it wasn’t flagged as urgent.
“When they (medical professionals) have a child with problems they can’t identify they should be looking at everything and checking everything.
“I just want people to be aware of this because (deaths) keep happening, nothing changes.
“We have had multiple meetings with the investigation team but it was quite a big shock when we saw (in the report) how much had gone on.
“Half the stuff in the doctors’ notes, we weren’t even told about. It says Archie had bronchial pneumonia but they never told us anything about that.”
Speaking to The Isle of Thanet News in December Jake said Archie was: “a happy little lad who was always smiling and loved to chew on his little sponge and brush when finally his first tooth came through around nine months old.
“Archie always loved to dance especially to the Fireman Sam theme tune, the sherry song by the Four Seasons, or My G by Aitch & Ed Sheeran.
“Lauren and I cherish memories of our time spent at the zoo, swimming, and holidays but especially bath time! Archie would bum shuffle and pull the funniest of faces which would brighten up any room.
“He’d wave at strangers and went shy when people gave him attention. He was adored by everyone lucky enough to have known him but was yet to build memories with his baby brother Albie.”
Lauren, 21, and Jake, 24, say to find out Archie might have been saved is heart-breaking.
Lauren said: “We are devastated. Knowing there was a chance to find what was wrong and save him is even more heart-breaking, he could have had a chance.
“Losing Archie has changed our lives completely. Archie was our firstborn and he was ripped away and life will never be the same again.
“Something (in East Kent Hospitals) needs to change, it just happens too often and you can look back at all the recommendations made and they are the same as those coming up for Archie.”
The investigation report outlines 13 recommendations which include reviewing current learning in place surrounding cardiology and respiratory conditions and providing training updates for the medical and nursing team and providing more compassionate care and behaviours training to enhance care received after child deaths.
A pre-inquest hearing has been scheduled to take place in Maidstone on August 1.
A Pre-Inquest Review is held if there are particular issues of law or procedure that need to be determined by the Coroner before the final inquest is held.
East Kent Hospitals University NHS Foundation Trust is responsible for hospitals including QEQM in Margate and William Harvey in Ashford.
Sarah Hayes, Chief Nursing and Midwifery Officer, 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.”
Taskforce
Last year it was announced that a national taskforce was to be set up to review “maternity and neonatal improvement programmes” across the UK in response to an independent investigation into maternity failings at QEQM and William Harvey Hospitals which found 45 baby deaths could have been avoided.
The then-Minister for women’s health strategy Maria Caulfield MP announced the measure as part of the government’s response to the inquiry carried out by Dr Bill Kirkup and his team.
NHS England and NHS Improvement commissioned Dr Bill Kirkup in 2020 to carry out an independent review into the circumstances of the maternity deaths at the East Kent Hospitals Trust sites in response to a concerning number of avoidable baby deaths.
Last December the Care Quality Commission (CQC) issued a warning notice to East Kent Hospitals University NHS Foundation Trust saying it must make immediate improvements in three services. Medical care and urgent and emergency care at QEQM were among areas that needed improvement. However, care for children and young people was rated as good.
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