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Sean Turner: Inquest rules 'lost opportunities' in four-year-old's care Sean Turner: Inquest rules 'lost opportunities' in four-year-old's care
(about 7 hours later)
A Bristol hospital has apologised over the treatment a four-year-old heart patient received on a ward after his parents condemned his care as “shambolic”.A Bristol hospital has apologised over the treatment a four-year-old heart patient received on a ward after his parents condemned his care as “shambolic”.
Steve, Steve, 47, and Yolanda Turner, 45, described some of the evidence they heard during the 10-day inquest into the death of their son Sean as "shocking and unacceptable".
47, and Yolanda Turner, 45, described some of the evidence they heard during Sean died in March 2012 from a brain hemorrhage after previously suffering a cardiac arrest, six weeks after he underwent vital corrective heart surgery.
the 10-day inquest into the death of their son Sean as "shocking and Mr and Mrs Turmer, from Warminster, told a hearing they begged medical staff to help their desperately ill son, who was being treated on Ward 32 of Bristol’s Children's Hospital.
unacceptable". They gave harrowing accounts of their son's care and treatment during a six-week stay at the hospital, which is regarded as a centre of excellence, saying Sean was so thirsty he resorted to sucking the moisture from tissues provided to cool his forehead.
Sean died in March 2012 from a brain hemorrhage after Mr and Mrs Turner accused doctors of transferring their son to Ward 32 from intensive care too soon and said they missed the signs of his worsening condition, such as rising blood pressure, vomiting and fluid loss from his chest.
previously suffering a cardiac arrest, six weeks after he underwent vital Sean's parents also criticised the University Hospitals Bristol NHS Trust, saying they did not believe it had learned lessons from their son's death.
corrective heart surgery. "Although Sean needed a high level of nursing attention, at times on Ward 32 he didn't even receive the most basic care”, they said.
Mr "We are relieved there have been changes made at the unit since Sean's death but we remain concerned that the risks to patients at Bristol may still be very real."
and Mrs Turmer, from Warminster, told a hearing they begged medical staff to Mr and Mrs Turner added: "There were many missed opportunities to rescue Sean from his desperate situation.
help their desperately ill son, who was being treated on Ward 32 of Bristol’s Children's Hospital. "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 Mr and Mrs Turner claim their son's death was not isolated and other children with heart problems have died at the hospital.
gave harrowing accounts of their son's care and treatment during a six-week Up 10 families are believed to be taking legal action against the University Hospitals Bristol NHS Foundation Trust over treatment on Ward 32.
stay at the hospital, which is regarded as a centre of excellence, saying Sean Together with the parents of seven-year-old Luke Jenkins, from Cardiff, Mr and Mrs Turner complained to the independent healthcare watchdog, the Care Quality Commission.
was so thirsty he resorted to sucking the moisture The CQC carried out an unannounced inspection and issued a formal warning to the hospital about standards on Ward 32.
from tissues provided to cool his forehead. It declared it failed to meet three essential standards of patient safety - on staffing levels, staff training and support, and overall care and welfare of patients.
Mr and Mrs Turner accused doctors of transferring their son to A five-bed high dependency unit has now been set up on Ward 32 and the trust commissioned its own independent review of paediatric nursing across the hospital with its findings implemented.
Ward 32 from intensive care too soon and said they missed the signs of his Trust chief executive Robert Woolley offered his "sincere apologies" to Mr and Mrs Turner for the "additional stress" caused in relation to Sean's death.
worsening condition, such as rising blood pressure, vomiting and fluid loss from "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.
his chest. "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.
Sean's parents also criticised the University Hospitals Bristol NHS Trust, saying they did not believe it Avon Coroner Maria Voisin recorded a narrative conclusion saying in her view there were "lost opportunities" with Sean's treatment but said this did not amount to neglect because there was not a "gross failure to provide basic care".
had learned lessons from their son's death. She also said she would not be writing a prevention of future deaths (PFD) report because of the changes the trust had made since the boy's death.
"Although Sean needed a high level of nursing attention, at "Sean Turner died on 15 March 2012 from complications from the Fontan operation undertaken on 25 January 2012," she said.
times on Ward 32 he didn't even receive the most basic care”, they said. "Following surgery he developed excessive fluid loss from his drains; elevated pressures in the Fontan circulation; the development of a thrombosis.
"We are relieved there have been changes made at the unit "The thrombus required treatment and Sean and died due to an intra-cerebral haemorrhage which is a known complication of the treatment of thrombolysis.
since Sean's death but we remain concerned that the risks to patients at Bristol may still be very real." "In addition there were lost opportunities to render medical care or treatment to Sean in this post-operative period which included management of his anti-coagulation from 6 February and not considering fenestration between 8 and 16 February."
Mr
and Mrs Turner added: "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."
Mr
and Mrs Turner claim their son's death was not isolated and other children with
heart problems have died at the hospital.
Up 10 families are believed to be taking legal action against the
University Hospitals Bristol NHS Foundation Trust over treatment on Ward
32.
Together with the parents of seven-year-old Luke Jenkins, from
Cardiff, Mr and Mrs Turner complained to the independent healthcare watchdog,
the Care Quality Commission.
The CQC carried out an unannounced inspection and issued a formal
warning to the hospital about standards on Ward 32.
It declared it failed to meet three essential standards of patient
safety - on staffing levels, staff training and support, and overall care and
welfare of patients.
A five-bed high dependency unit has now been set up on Ward 32 and
the trust commissioned its own independent review of paediatric nursing across
the hospital with its findings implemented.
Trust chief executive Robert Woolley offered his "sincere apologies" to Mr and Mrs
Turner for the "additional stress" caused in relation to Sean's death.
"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.
"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.
Avon Coroner Maria Voisin recorded a narrative conclusion saying
in her view there were "lost opportunities" with Sean's treatment but
said this did not amount to neglect because there was not a "gross failure
to provide basic care".
She also said she would not be writing a prevention of future
deaths (PFD) report because of the changes the trust had made since the boy's
death.
"Sean Turner died on 15 March 2012 from complications from
the Fontan operation undertaken on 25 January 2012," she said.
"Following surgery he developed excessive fluid loss from his
drains; elevated pressures in the Fontan circulation; the development of a
thrombosis.
"The thrombus required treatment and Sean and died due to an
intra-cerebral haemorrhage which is a known complication of the treatment of
thrombolysis.
"In addition there were lost opportunities to render medical
care or treatment to Sean in this post-operative period which included management
of his anti-coagulation from 6 February and not considering fenestration
between 8 and 16 February."
Additional reporting by Press AssociationAdditional reporting by Press Association