A hospital trust has been ordered to apologise to the bereaved parents of a four-year-old boy left so dehydrated after heart surgery he sucked liquid from wet wipes.
Sean Turner, four, was born with his heart on the right side of his body and died from a brain haemorrhage six weeks after he underwent corrective surgery.
An inquest in 2014 heard claims from Sean’s parents he was left so dehydrated due to a lack of care by nurses that they found him sucking wet wipes for moisture.
Now a far-reaching inquiry by the Parliamentary and Health Service Ombudsman said the lad’s aftercare at Bristol Children’s Hospital amounted to “service failure”.
Nine experts ruled University Hospital Bristol Foundation Trust was guilty of maladministration for failing to be open with Sean’s parents.
It also ruled Sean, from Warminster, Wilts., was “not given the best possible chance of survival” and found 22 failures by nurses and doctors.
The trust has now been ordered to write “an open and honest acknowledgement of the failings identified” in the report and “an apology of the impact”.
The inquiry did not find that Sean would definitely have survived without the trust’s failings.
But it added: “Nevertheless, the distress Mr and Mrs Turner have suffered, and continue to suffer, will undoubtedly be compounded by the uncertainty – however small – of never knowing whether Sean might have survived if everything that should have been done for him, had been done.”
Sean was born with his heart on the right side of his body and died in March 2012 from a brain haemorrhage after previously suffering a cardiac arrest, six weeks after he underwent corrective heart surgery.
His parents Steve and Yolanda Turner accused doctors of transferring their son to Ward 32 from intensive care too soon.
They said they missed signs of his worsening condition, with rising blood pressure, vomiting and fluid loss from his chest.
During the inquest Mrs Turner, told the coroner: “Over four days 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 suck the water out of them.
“‘He kept asking for drinks but we were told he was on a fluid restriction to clear out his drains and this was normal.
“This was not normal, our little boy was switching off, in terrible pain, struggling to breathe and had an increasing heart rate.
“We tried so hard to get him some help.
“Nothing happened, 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.”
Sean suffered a cardiac arrest on February 16 and returned to the intensive care unit where he remained until he died on March 15.
Coroner Maria Voisin said in 2014 she had not heard evidence of any “gross failures to provide basic care”, but the hospital apologised.
An inquiry commissioned by NHS England medical director Sir Bruce Keogh was launched into the children’s hospital where 11 youngsters died in four years.
It heard from 237 families whose children were treated on the ward and compiled expert case reports into the care of 27 children.
Families labelled it a “whitewash” after it said there were “serious pressures” but concluded there was “no evidence to suggest that there were failures in care and treatment” in June.
But this recent report by the ombudsman responsible for considering complaints by the public highlighted systematic failures in the level of care experienced by Sean.
It said he should have been moved back to intensive care rather than being left on Ward 32 and his fluid input and output was not measured accurately by ward nurses.
It also said the risk of him developing a blood clot would have been lower if he had been keep properly hydrated and his blood thinning medication was not stopped when medics suspected a brain bleed.
Robert Woolley, chief executive of the trust, said: “I would like to extend our condolences again to Sean Turner’s family for the sad loss of their son.
“I am deeply sorry for our failings in care and for the impact they had on Sean and his family. We want to get our care right for every child, every time, and I bitterly regret that we didn’t do this for Sean. I am also very sorry that we compounded their grief by giving inaccurate and incomplete responses to their subsequent complaint.
“While the Ombudsman specifically investigated Sean’s care in 2012, the Care Quality Commission reviewed a random sample of complex children’s cardiac cases between 2012 and 2014 and the Independent Review commissioned by NHS England examined not only the detail of many individual cases but the overall operation, quality and governance of our children’s heart service from 2010 to 2014.
“All these reviews found examples of good care and all of them noted that we had made significant improvements since 2012 in our infrastructure, procedures, staffing, training and bereavement support. We are particularly determined to strengthen the partnership between families and staff which is the basis of safe and effective, high quality care.
“We have formally apologised to Sean’s parents. We remain in contact with them and we will ensure that they are fully informed about all the improvements we have made and continue to make in response to the findings of the recent reviews.”