Coroner: options had been lost in care of boy who died at Bristol hospital

There were “misplaced options” in the care of a 4-year-outdated boy who died as he was taken care of on a controversial hospital ward after a heart operation, a coroner has ruled.

During his inquest, Sean Turner’s dad and mom, Yolanda and Steve, claimed their son was let down by a shortage of workers and a lack of skills on ward 32 at Bristol royal children’s hospital. They said he was so desperate for water whilst he recovered from the operation that he resorted to sucking liquid from moisturised tissues.

Providing a narrative verdict, the Avon coroner Maria Voisin stated: “Sean Turner died on 15 March 2012 from complications from the operation undertaken on 25 January 2012.” She continued: “There had been lost opportunities to render health-related care or treatment method to Sean in this publish-operative time period.”

Nonetheless, the coroner stated she had not heard proof of any “gross failures to offer basic care” in Sean’s treatment on ward 32. She also mentioned that getting heard of the adjustments the hospital had produced she would not be creating a “prevention of potential deaths” report to the believe in, adding: “I am conscious that the trust has manufactured plenty of changes because Sean’s death and I do not consider that I need to make any report in connection with this matter.”

Soon after the hearing, the Turners heavily criticised the hospital. They explained: “At the time of Sean’s surgical procedure in January 2012, Bristol claimed to be a centre of excellence with a specialist cardiac unit.

“Even though Sean essential a high level of nursing consideration, at occasions on ward 32 he did not even get the most fundamental care. There was a lack of leadership, accountability and communication.”

They said what they had discovered about the hospital was “shocking and unacceptable”, incorporating: “There had been numerous missed options to rescue Sean from his desperate situation. In our opinion, Sean was in the incorrect hospital with the incorrect surgeon. We now have to try out and rebuild our lives with out our tiny boy.”

Ahead of the inquest, Mrs Turner tweeted: “two yrs ago today Bristol asked us to carry Sean in for his fontan [the heart process] he was so excited! Today two yrs later on we await anxiously his inquest verdict.”

For the duration of the hearing Mrs Turner claimed a medical doctor had stopped her and husband, Steve, from looking for the suggestions of a retired Fantastic Ormond Street hospital surgeon since “he would by no means go to London for a 2nd view”.

She mentioned: “Sean was deteriorating. We could see it but nobody listened to us. We asked so numerous occasions and so a lot of personnel – from ward medical doctors, outreach nurses, cardiac liaison nurse and the nurses – if Sean could go back to intensive care as he had been far better there. We have been informed no beds or that merely he was not vital ample.

“Sean had escalating heart fee, was constantly being sick and was turning into so chronically dehydrated he was grabbing tissues utilized to amazing his forehead and sucking the water out of them. Our little boy was switching off, in horrible pain, struggling to breathe.”

Mrs Turner, a foster carer, mentioned nurses did not react to automated alarm calls on her son’s monitoring gear, carry out regular checks or fill in his record charts.

“No one seemed to assist. Nurses have been concerned but they appeared also occupied to give the time necessary to care for Sean at the level he essential,” she mentioned.

“Each nap he had I sat and cried as I felt so desperate and so helpless. Why would no one pay attention? We will in no way neglect the days on ward 32 and can in no way understand how a little one can be left to endure for so prolonged.”

Ward 32, the children’s cardiac ward, was severely criticised in October 2012, when the Care Quality Commission located there have been inadequate well-experienced nurses for the variety of individuals and issued a warning recognize requiring University Hospitals Bristol NHS foundation trust to consider quick action, which it did.

An inquest on yet another boy, Luke Jenkins, 7, who died in April 2012 soon after being taken care of on the ward, heard complaints strikingly similar to the Turners’ at the end of final yr. Up to 10 households, including people of Sean and Luke, are believed to be taking legal action towards the trust.

Two much more inquests involving youngsters treated at the hospital are scheduled for next month and March.

Mrs Turner, from Warminster, Wiltshire, informed the inquest she grew to become so upset on a single event that her husband advised her to depart so that Sean would not see her anguish. When she returned her son was surrounded by medical professionals obtaining suffered a cardiac arrest. The boy survived and Mrs Turner said they asked if he could be transferred to yet another hospital but were informed he was too poorly. Nor would they let the parents to have a second view, she claimed.

Later he suffered what his mom described as a “severe brain bleed” and doctors advised his parents there was absolutely nothing far more they could do. Mrs Turner stated they cuddled him and explained goodbye. “Sean fought so hard. There had been so many missed options,” she stated.

Throughout the inquest a senior nurse conceded there had been “deficiencies” in the care that Sean obtained whilst on ward 32.

William Booth, who is the matron and lead nurse for paediatric crucial care solutions, stated: “I can accept there have been deficiencies in care and that the [staffing] ratios could have been much better.

Booth outlined the modifications that had been created on ward 32, this kind of as strengthening staffing amounts, coaching, communication with dad and mom and the setting up of a large dependency unit inside of the ward.

He explained that inside the newly developed 5-bed higher dependency unit there was a ratio of patients to nurses of 2:1 and throughout the remainder of the ward it was now three:1.

Robert Woolley, chief executive of the University Hospitals Bristol NHS basis believe in, apologised to the Turners.

He mentioned: “The coroner has heard that their son Sean was born with a quite uncommon and complex heart situation and was undergoing a process which carries a known risk of death.

“But the inquest has also highlighted some missed possibilities in the care we gave to Sean when managing his post-operative issues and shortcomings in our communication with the loved ones.

“I would like to provide my sincere apologies to Mr and Mrs Turner for the extra stress that we have caused them in relation to Sean’s death.

“We are always improving our companies and we have produced substantial adjustments given that Sean was on the ward in early 2012. Regardless of Sean’s sad death, our outcomes are comparable to other national centres for this kind of surgery.

“We will, of course, proceed to reflect on Sean’s death, the coroner’s conclusion and the evidence heard more than the final seven days and we will guarantee we have identified all achievable lessons for potential care of kids like Sean.”

Mr and Mrs Turner explained: “We stay concerned that the dangers to sufferers at Bristol could still be really genuine. We have not noticed enough proof to persuade us that the lessons of Sean and Luke Jenkins’ deaths, much less than a month apart, have been learnt.”

Coroner: options had been lost in care of boy who died at Bristol hospital