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.'

Try Our AI Features

Explore what Daily8 AI can do for you:

Learn with AIFact CheckingText to SpeechAI Summary

Related Articles

BBC News

14 hours ago

• BBC News

Holocaust survivors' families visit former Kent refugee site

Families of Holocaust survivors have visited a Kent army base that helped rescue thousands of Jewish members of the Association of Jewish Refugees (AJR) visited the Kitchener Camp at Sandwich on Thursday, which had been a haven from the Nazis for their parents and grandparents in group also saw an exhibition at the town's Guildhall Museum which had materials from the Kitchener Camp Project – an online resource bringing together records and family treasures to build a picture of the unlikely website's founder Clare Weissenberg described the day's visit as "profound". "Werner, my father, always kept a suitcase of letters, documents and photographs under the bed at home, all of which never saw the light of day," she said."I was in my early 20s when he died, which is when I found paperwork with the German eagle insignia stamped on it."So I began wondering about his story."Whilst volunteering at The Wiener Holocaust Library in London, Ms Weissenberg met the author Clare Ungerson, who had been chronicling the lives of families just like hers. Hearing tales of some 4,000 others who had similarly fled to Kent to escape Hitler's campaign of ethnic cleansing was like "a cork being taken out of a bottle", she said."Afterwards I set up a Kitchener Camp website and got a great response from all over, with people sending me their own experiences."It really seemed to grab everyone's imagination and I gradually built a picture of this largely forgotten and overlooked piece of history."The Kitchener Camp rescue began in February 1939, seven months before the outbreak of World War Two and shortly after the Nazis coordinated a wave of antisemitic violence known as Kristallnacht, or the Night of Broken rescue was founded and run by the same, mainly Jewish, aid organisations that funded and coordinated the far better known Kindertransport scheme. Stephen Nelken said his father Lothar had escaped fascism and a lengthy internment at a concentration camp. "I found his diary from when he left Germany and came to Kitchener Camp," said Mr Nelken, adding that the people of Sandwich had been "very welcoming" to his dad - even buying him and his fellow refugees a round of pints at the local pub."It's really important to know what went on and that it is passed onto his grandchildren as well," he Ungerson, whose book Four Thousand Lives is about the Kitchener Camp, said she was "surprised how few of these men's descendants knew anything of what happened to their fathers, grandfathers and uncles"."And, to be so at ease with having a camp of refugees in its midst, Sandwich must have been an extraordinary place," she added.

BBC News

20 hours ago

• BBC News

Petition to reinstate Tilbury to Gravesend ferry to be debated

Businesses are backing calls to reinstate the river crossing service between Gravesend in Kent and Tilbury in the operator of the service, announced last year it would not renew its Party member Rebecca Drake started a petition, which collected more than 2,400 signatures, and has been submitted to Kent County Council (KCC) to be debated at a council cabinet meeting on 17 KCC says it remains "committed" to working with other partners to explore "a sustainable, long-term solution for a replacement service, should funding become available". Ms Drake said she started her campaign last year after speaking to residents about how the closure had impacted them. "The service was a lifeline to the communities. Gravesend businesses have reported a noticeable downturn in revenue," she Drake, who ran as a parliamentary candidate in Gravesend last year, added: "Reinstating the ferry means there are more alternative transportation options and less pressure on roads." Glen White, owner of gaming cafe The Mug and Meeple in Gravesend, said the ferry was a "vital service" for businesses and residents in both towns."It was a shame the ferry stopped operating. It was a cost-effective way of travel for work, school and shopping," he Langley, owner of Gravesend Models & Wargames, said he had seen a fall in customer numbers visiting his shop."Many people, especially older people, came to Gravesend for shopping because it was convenient," he than 100,000 passenger journeys were made every year on the ferry service, according to KCC. A spokesperson for KCC said: "We understand the disappointment surrounding the withdrawal of the Tilbury ferry service. "Without joint funding from Thurrock District Council, we are currently unable to support the service independently due to ongoing budget constraints."Thurrock Council has been approached for a comment.

Telegraph

a day ago

• Telegraph

City executive sues plumbers after £1m house ‘made family seriously ill'

A former City executive has filed a legal claim against the plumbers who allegedly fitted faulty pipes that leaked excrement through her £1 million home, making her family seriously ill. Danielle Mensah, 45, is also suing the developers who sold her the five-bedroom home in Beckenham, Kent, a decade ago. Mrs Mensah, who has been named in the top 100 women in the City, claims a botched soil pipe from the bathroom toilet caused a build-up of waste that made her whole family unwell. The case alleges that exposure to the waste left the family with chronic inflammatory response syndrome (CIRS) – a condition not recognised in mainstream European medicine. The family said the offending soil pipe was hidden by boxwork and a wall, but still omitted toxins and mould which over time caused symptoms including fatigue, frequent urination, headaches, blurred vision, diarrhoea and vertigo. Mrs Mensah and her husband, Daniel, have initiated a claim of more than £200,000 against plumbers RG Evans and developers Linden Home. The couple, who are parents to children aged eight and two, moved into the development of 48 detached houses in May 2015. According to their High Court claim, both started to develop strange, debilitating symptoms. Mrs Mensah, who now works as a leadership coach, is said to have started experiencing fatigue and blurred vision, while needing to get up 15 times each night to go to the loo, alongside headaches, cramping, vertigo and cognitive problems which cumulatively caused her to take time off work in 2020. She claims to still require treatment for digestive issues, tiredness, insomnia, weakness, headaches and a deficient working memory, as well as anxiety about being reinfected. Her 40-year-old husband also suffered insomnia, frequent urination and fatigue, as well as mood swings, constipation and sweating, but has seen his condition improve from treatment such as cognitive behavioural therapy. Mr Mensah first noticed staining in an en suite bathroom in 2020. A tradesman then allegedly found that the soil pipe had not been solvent-welded and was propped up by plasterboard rather than being fixed by a bracket. Readings conducted by a company called Building Forensics Report found potential contamination from black water and levels of potentially toxic bacteria were between 10 and 100 times the usual level, according to court documents. A survey using a 'Mouldscope'' revealed a 'red' high mould concentration in all rooms bar one, with none showing the green expected for a residential property, the couple claimed. The family said they were advised to sell their home, moving out in November 2020 and into temporary accommodation. The family has accused both the plumbers and developers of negligence and breach of contract or duty, and are seeking damages for their injuries and the distress and inconvenience caused. Vistry Group, Linden's parent company, has said: 'This matter is the subject of active court proceedings and, on that basis, we decline to comment.'