'Missed opportunities' to prevent baby's death

A baby boy "almost certainly would not have died when he did" if his rare heart condition had been diagnosed, an inquest has found.

Archie Squire suffered heart failure days after his first birthday and died in November 2023 after multiple visits to the Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate.

The inquest at North East Kent Coroner's Court, Maidstone, heard how Archie was reviewed at the A&E and Urgent Care Centre at QEQM Hospital more than 10 times during his life, displaying symptoms including constipation, breathlessness and failure to thrive.

Area coroner for North East Kent, Sarah Clarke, concluded that there was "no doubt" that an earlier diagnosis of a congenital heart defect would have "altered the outcome" of Archie Squire’s care and echoed a report by East Kent Hospitals University NHS Foundation Trust, which highlighted "missed opportunities" that could have prevented his death.

Delivering her conclusion, Ms Clarke recorded Archie's cause of death as heart failure and congenitally corrected transposition of the great arteries (CCTGA).

This defect could have been diagnosed by an echocardiogram, which Ms Clarke said was not undertaken despite "many presentations to medical personnel in the weeks and months leading up to his death." 

In a report to the court, a paediatric cardiac surgeon described the delay as "unacceptable" while a paediatrician from East Kent Hospitals told the inquest that it was "a surprise" to find that Archie Squire had a cardiac issue as he did not have any signs of heart disease or heart failure in October 2023.

Ms Clarke added: "There is no doubt that earlier recognition and diagnosis of Archie's underlying heart condition would have altered the outcome.

"I am not saying what that outcome would have been. He almost certainly would not have died when he did."

Ms Clarke made no judgement on individual decisions but said there were missed opportunities for a more proactive approach during October, adding a more holistic approach should have been taken.    /more…

The coroner added that new and more robust systems had been put in place by the trust since Archie's death.

Speaking directly to Archie's family, Ms Clarke praised them as an "absolute credit to each other."

Speaking after the inquest, Archie's parents, Jake Squire and Lauren Parrish, said they "do not feel reassured that a baby going through heart failure in the same way Archie had for months would be correctly diagnosed."

Speaking outside North East Kent Coroner's Court in Maidstone, Mr Squire 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 heartbreaking."

Ms Parrish recalled her son was labelled a "mystery child" because doctors were not sure what was wrong with him. He died in the early hours of November 2023, three days after his first birthday, following two cardiac arrests.

Archie's godmother, Nikki Escudier, described Archie as a "shining light" whose "laughter, love and joy touched everyone lucky enough to know him."

Chief executive of East Kent Hospitals University NHS Foundation Trust (EKH), Tracey Fletcher, said the trust was "truly sorry."

In a statement on behalf of the trust, Ms Fletcher added: "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."