An inquest into the death of one-year-old Archie Squire has concluded with the Coroner finding there had been missed opportunities to identify his rare heart condition,
Archie died on 23 November 2023 following two cardiac arrests.
The “happy little lad who was always smiling” had been reviewed in the A&E and Urgent Care Centre at Queen Elizabeth the Queen Mother (QEQM) hospital in Margate more than 10 times since his birth on November 20, 2022, with symptoms including constipation, breathlessness and failure to thrive.
The day after his first birthday, Archie was admitted to the hospital from A&E due to constipation and vomiting.
He died two days later after suffering two separate cardiac arrests. A postmortem examination found that Archie had a rare heart condition, which had gone undetected.
Recording a narrative conclusion, Kent North East Area Coroner, Sarah Clarke said Archie died from heart failure and congenitally corrected transposition of the great arteries (ccTGA). ccTGA, is a rare heart defect in which the heart’s ventricles and great arteries are reversed.
Records show that Archie 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 on-going referrals and triaging.
Archie’s parents, Jake Squire and Lauren Parish, have urged parents to speak out if they feel there is something wrong with their child.
The couple, who now live in Margate, said: “It has been incredibly difficult to sit and listen to the evidence over the last couple of weeks. Archie was a happy baby, but he was not a well baby and me and Lauren, did all that we could during his short life to seek help for him. We trusted the doctors and nurses who cared for him to take our concerns seriously and to find out what was wrong.
“To learn after his death that he had such a serious problem with his heart that had not been diagnosed, despite the number of times we took him to hospital, was heart-breaking.
“As well as the traumatic events of the night Archie died, and the unimaginable grief of losing our baby boy, we now also have to live with a devastating reality: the doctors we trusted to care for Archie missed opportunities to diagnose the heart condition that took him from us just days after his first birthday.
“Had the scan needed of his heart been carried out, and his condition diagnosed, Archie almost certainly would not have died when he did.
“After listening to the evidence, we do not feel reassured that a baby going through heart failure, in the same way Archie had for months would be correctly diagnosed.
“We are very concerned that medical staff will continue to diagnose babies like Archie with chest infections or bronchiolitis simply because they are more common than heart failure.
“We are left feeling that we cannot put our trust in clinicians and would urge all parents of young babies to trust their instincts and to speak up for those children who do not have a voice for themselves.
“If your instincts are telling you that something is not quite right we encourage you to use your voice and to fight for what you believe your baby needs.
“Lastly, we would like to thank the coroner for her detailed investigation into what happened to Archie. As a family we now ask for privacy while we take the time to process everything we’ve heard.”
‘Strength and resilience’
Lily Hedgman, a solicitor from the medical negligence team at Leigh Day, that represented the couple, said: “Lauren, Jake and the rest of Archie’s family have shown incredible courage as they have navigated this difficult process.
“I remain entirely in awe of the strength and resilience they have shown in the face of the harrowing evidence we have listened to over the last couple of weeks.
“The coroner’s findings of fact were very clear.
“Archie died of a rare heart condition and had been in heart failure for months before his death.
“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.
“Despite their unimaginable grief, Archie’s family have been motivated through this process by a selfless goal of trying to prevent another family having to endure what they have been through. Lessons must be learned from Archie’s all too short life.
“We hope that going forward clinicians will take all the necessary steps to exclude a cardiac cause when babies repeatedly present with the same symptoms as Archie.”
Archie’s inquest considered evidence from 27 witnesses across eight days at Oakwood House, Oakwood Park, Maidstone, ME16 8AE. It began on Monday 19 May 2025 and concluded today (May 30).
The coroner praised the strength shown by Archie’s family, including the parents, grandparents, great grandparent, aunties, uncles and Archie’s godmother who have been in court throughout the inquest process.
‘Truly sorry’
Tracey Fletcher, Chief Executive, 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.”
As part of the review undertaken following Archie’s death the Trust says there have been changes including teaching and simulation with a focus on rare cardiac conditions and compassionate communication with families; a new standardised process for triage and appointment booking in all specialities within children’s health, including cardiology; updated guidelines for the ‘Recognition of Faltering and Atypical Growth in Infants and Children’ and improvements to the system of review for children with multiple attendances to the emergency department.
