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| Coroner: opportunities were lost in care of boy who died at Bristol hospital | Coroner: opportunities were lost in care of boy who died at Bristol hospital |
| (about 2 hours later) | |
| There were "lost opportunities" in the care of a four-year-old boy who died as he was treated on a controversial hospital ward after a heart operation, a coroner has ruled. | There were "lost opportunities" in the care of a four-year-old boy who died as he was treated on a controversial hospital ward after a heart operation, a coroner has ruled. |
| During his inquest, Sean Turner's parents, Yolanda and Steve, claimed their son was let down by a shortage of staff and a lack of expertise on ward 32 at Bristol Royal Children's hospital. They said he was so desperate for water while he recovered from the operation that he resorted to sucking liquid from moisturised tissues. | |
| Giving a narrative verdict, the Avon coroner Maria Voisin said: "Sean Turner died on 15 March 2012 from complications from the operation undertaken on 25 January 2012." She continued: "There were lost opportunities to render medical care or treatment to Sean in this post-operative period." | Giving a narrative verdict, the Avon coroner Maria Voisin said: "Sean Turner died on 15 March 2012 from complications from the operation undertaken on 25 January 2012." She continued: "There were lost opportunities to render medical care or treatment to Sean in this post-operative period." |
| However, the coroner said she had not heard evidence of any "gross failures to provide basic care" in Sean's treatment on ward 32. She also said that having heard of the changes the hospital had made she would not be writing a "prevention of future deaths" report to the trust, adding: "I am aware that the trust has made lots of changes since Sean's death and I do not consider that I need to make any report in connection with this matter." | However, the coroner said she had not heard evidence of any "gross failures to provide basic care" in Sean's treatment on ward 32. She also said that having heard of the changes the hospital had made she would not be writing a "prevention of future deaths" report to the trust, adding: "I am aware that the trust has made lots of changes since Sean's death and I do not consider that I need to make any report in connection with this matter." |
| After the hearing, the Turners heavily criticised the hospital. They said: "At the time of Sean's surgery in January 2012, Bristol claimed to be a centre of excellence with a specialist cardiac unit. | After the hearing, the Turners heavily criticised the hospital. They said: "At the time of Sean's surgery in January 2012, Bristol claimed to be a centre of excellence with a specialist cardiac unit. |
| "Although Sean needed a high level of nursing attention, at times on ward 32 he didn't even receive the most basic care. There was a lack of leadership, accountability and communication." | "Although Sean needed a high level of nursing attention, at times on ward 32 he didn't even receive the most basic care. There was a lack of leadership, accountability and communication." |
| They said what they had discovered about the hospital was "shocking and unacceptable", adding: "There were many missed opportunities to rescue Sean from his desperate situation. In our opinion, Sean was in the wrong hospital with the wrong surgeon. We now have to try and rebuild our lives without our little boy." | They said what they had discovered about the hospital was "shocking and unacceptable", adding: "There were many missed opportunities to rescue Sean from his desperate situation. In our opinion, Sean was in the wrong hospital with the wrong surgeon. We now have to try and rebuild our lives without our little boy." |
| Before the inquest, Mrs Turner tweeted: "2 yrs ago today Bristol asked us to bring Sean in for his fontan [the heart procedure] he was so excited! Today 2 yrs later we await anxiously his inquest verdict." | Before the inquest, Mrs Turner tweeted: "2 yrs ago today Bristol asked us to bring Sean in for his fontan [the heart procedure] he was so excited! Today 2 yrs later we await anxiously his inquest verdict." |
| During the hearing Mrs Turner claimed a doctor had stopped her and her husband, Steve, from seeking the advice of a retired Great Ormond Street hospital surgeon because "he would never go to London for a second opinion". | |
| She said: "Sean was deteriorating. We could see it but nobody listened to us. We asked so many times and so many staff – from ward doctors, outreach nurses, cardiac liaison nurse and the nurses – if Sean could go back to intensive care as he had been better there. We were told no beds or that simply he was not critical enough. | She said: "Sean was deteriorating. We could see it but nobody listened to us. We asked so many times and so many staff – from ward doctors, outreach nurses, cardiac liaison nurse and the nurses – if Sean could go back to intensive care as he had been better there. We were told no beds or that simply he was not critical enough. |
| "Sean had increasing heart rate, was constantly being sick and was becoming so chronically dehydrated he was grabbing tissues used to cool his forehead and sucking the water out of them. Our little boy was switching off, in terrible pain, struggling to breathe." | "Sean had increasing heart rate, was constantly being sick and was becoming so chronically dehydrated he was grabbing tissues used to cool his forehead and sucking the water out of them. Our little boy was switching off, in terrible pain, struggling to breathe." |
| Mrs Turner, a foster carer, said nurses did not respond to automatic alarm calls on her son's monitoring equipment, carry out regular checks or fill in his record charts. | Mrs Turner, a foster carer, said nurses did not respond to automatic alarm calls on her son's monitoring equipment, carry out regular checks or fill in his record charts. |
| "Nobody seemed to help. Nurses were concerned but they seemed too busy to give the time needed to care for Sean at the level he needed," she said. | "Nobody seemed to help. Nurses were concerned but they seemed too busy to give the time needed to care for Sean at the level he needed," she said. |
| "Every nap he had I sat and cried as I felt so desperate and so helpless. Why would no one listen? We will never forget the days on ward 32 and can never understand how a child can be left to suffer for so long." | "Every nap he had I sat and cried as I felt so desperate and so helpless. Why would no one listen? We will never forget the days on ward 32 and can never understand how a child can be left to suffer for so long." |
| Ward 32, the children's cardiac ward, was severely criticised in October 2012, when the Care Quality Commission found there were insufficient well-qualified nurses for the number of patients and issued a warning notice requiring University Hospitals Bristol NHS foundation trust to take immediate action, which it did. | Ward 32, the children's cardiac ward, was severely criticised in October 2012, when the Care Quality Commission found there were insufficient well-qualified nurses for the number of patients and issued a warning notice requiring University Hospitals Bristol NHS foundation trust to take immediate action, which it did. |
| An inquest on another boy, Luke Jenkins, seven, who died in April 2012 after being treated on the ward, heard complaints strikingly similar to the Turners' at the end of last year. Up to 10 families, including those of Sean and Luke, are believed to be taking legal action against the trust. | An inquest on another boy, Luke Jenkins, seven, who died in April 2012 after being treated on the ward, heard complaints strikingly similar to the Turners' at the end of last year. Up to 10 families, including those of Sean and Luke, are believed to be taking legal action against the trust. |
| Two more inquests involving children treated at the hospital are scheduled for next month and March. | Two more inquests involving children treated at the hospital are scheduled for next month and March. |
| Mrs Turner, from Warminster, Wiltshire, told the inquest she became so upset on one occasion that her husband advised her to leave so that Sean would not see her anguish. When she returned her son was surrounded by doctors having suffered a cardiac arrest. The boy survived and Mrs Turner said they asked if he could be transferred to another hospital but were told he was too poorly. Nor would they allow the parents to have a second opinion, she claimed. | Mrs Turner, from Warminster, Wiltshire, told the inquest she became so upset on one occasion that her husband advised her to leave so that Sean would not see her anguish. When she returned her son was surrounded by doctors having suffered a cardiac arrest. The boy survived and Mrs Turner said they asked if he could be transferred to another hospital but were told he was too poorly. Nor would they allow the parents to have a second opinion, she claimed. |
| Later he suffered what his mother described as a "serious brain bleed" and doctors told his parents there was nothing more they could do. Mrs Turner said they cuddled him and said goodbye. "Sean fought so hard. There were so many missed opportunities," she said. | Later he suffered what his mother described as a "serious brain bleed" and doctors told his parents there was nothing more they could do. Mrs Turner said they cuddled him and said goodbye. "Sean fought so hard. There were so many missed opportunities," she said. |
| During the inquest a senior nurse conceded there were "deficiencies" in the care that Sean received while on ward 32. | During the inquest a senior nurse conceded there were "deficiencies" in the care that Sean received while on ward 32. |
| William Booth, who is the matron and lead nurse for paediatric critical care services, said: "I can accept there were deficiencies in care and that the [staffing] ratios could have been better. | William Booth, who is the matron and lead nurse for paediatric critical care services, said: "I can accept there were deficiencies in care and that the [staffing] ratios could have been better. |
| Booth outlined the changes that had been made on ward 32, such as improving staffing levels, training, communication with parents and the setting up of a high dependency unit within the ward. | Booth outlined the changes that had been made on ward 32, such as improving staffing levels, training, communication with parents and the setting up of a high dependency unit within the ward. |
| He said that within the newly created five-bed high dependency unit there was a ratio of patients to nurses of 2:1 and throughout the remainder of the ward it was now 3:1. | He said that within the newly created five-bed high dependency unit there was a ratio of patients to nurses of 2:1 and throughout the remainder of the ward it was now 3:1. |
| Robert Woolley, chief executive of the University Hospitals Bristol NHS foundation trust, apologised to the Turners. | Robert Woolley, chief executive of the University Hospitals Bristol NHS foundation trust, apologised to the Turners. |
| He said: "The coroner has heard that their son Sean was born with a very rare and complex heart condition and was undergoing a procedure which carries a known risk of death. | He said: "The coroner has heard that their son Sean was born with a very rare and complex heart condition and was undergoing a procedure which carries a known risk of death. |
| "But the inquest has also highlighted some missed opportunities in the care we gave to Sean when managing his post-operative complications and shortcomings in our communication with the family. | "But the inquest has also highlighted some missed opportunities in the care we gave to Sean when managing his post-operative complications and shortcomings in our communication with the family. |
| "I would like to offer my sincere apologies to Mr and Mrs Turner for the additional stress that we have caused them in relation to Sean's death. | "I would like to offer my sincere apologies to Mr and Mrs Turner for the additional stress that we have caused them in relation to Sean's death. |
| "We are always improving our services and we have made significant changes since Sean was on the ward in early 2012. Despite Sean's sad death, our outcomes are comparable to other national centres for this type of surgery. | "We are always improving our services and we have made significant changes since Sean was on the ward in early 2012. Despite Sean's sad death, our outcomes are comparable to other national centres for this type of surgery. |
| "We will, of course, continue to reflect on Sean's death, the coroner's conclusion and the evidence heard over the last seven days and we will ensure we have identified all possible lessons for future care of children like Sean." | "We will, of course, continue to reflect on Sean's death, the coroner's conclusion and the evidence heard over the last seven days and we will ensure we have identified all possible lessons for future care of children like Sean." |
| Mr and Mrs Turner said: "We remain concerned that the risks to patients at Bristol may still be very real. We have not seen enough evidence to persuade us that the lessons of Sean and Luke Jenkins' deaths, less than a month apart, have been learnt." | Mr and Mrs Turner said: "We remain concerned that the risks to patients at Bristol may still be very real. We have not seen enough evidence to persuade us that the lessons of Sean and Luke Jenkins' deaths, less than a month apart, have been learnt." |