A boy died after staff at a South London hospital failed to spot his serious bowel condition on multiple occasions, a coroner has said.
Sam Parkin was seen several times at St George’s Hospital, in Tooting, over the course of his life – in A&E in 2013, 2015 and 2016, and as an outpatient in 2016 and 2022 – before he died on September 16, 2022, a month before his 10th birthday.
At times he had been vomiting a green substance which should have been a prompt to carry out further tests.
Doctors had failed to diagnose Sam with malrotation, where the intestines do not rotate into their correct position during foetal development. He died of a hypoxic brain injury three days after suffering a cardiac arrest outside of hospital caused by midgut volvulus – the twisting of the intestine around its blood supply – due to his undiagnosed malrotation.
In a prevention of future deaths report, Ellie Oakley, Assistant Coroner for Inner West London, said malrotation was only listed as a potential diagnosis in Sam’s notes when he was admitted to hospital in 2015. She said doctors carried out an ultrasound during this admission but not an upper gastrointestinal (GI) study, also known as a barium swallow, which likely would have led to them discovering his bowel condition and treating it with surgery.
The coroner said it appeared there was “a miscommunication or misunderstandings” between teams surrounding what had and had not been considered and excluded by each during Sam’s admission in 2015.
Ms Oakley ruled: “Sam was misdiagnosed. Having considered the evidence, including the opinion of the expert witness, I found that the repeated nature of Sam’s symptoms (in particular, vomiting which was sometimes green and severe abdominal pain) over a number of years meant that an upper GI contrast study should have been carried out to look for malrotation.”
She said if a test had been conducted it is likely that it would have identified the malrotation, or at least prompted further tests that would have discovered it. Surgery could then have been carried out, “significantly reducing the risk of volvulus and Sam’s ultimate death”.
Ms Oakley said the misdiagnosis and incorrect reassurance and advice that Sam’s parents had been given over the years meant they did not know to bring him into hospital earlier when he suffered the fatal volvulus.
NHS changes to prevent a repeat
St George’s University Hospitals NHS Foundation Trust said it had made several improvements following Sam’s death, in response to Ms Oakley’s report. It has improved training, changed its practices in reporting ultrasound scans to avoid potential confusion and reduced the threshold for requesting upper gastrointestinal studies for people experiencing intermittent abdominal pain and vomiting.
The trust has also rewritten guidance on management of abdominal pain in children to make sure the correct imaging is requested. It now holds a monthly paediatric gastroenterology radiology meeting where complex cases are discussed, improving communication between staff and allowing uncertainty over diagnoses to be openly discussed.
A St George’s University Hospitals NHS Foundation Trust spokesperson said: “We would like to offer our sincerest apologies to Samuel Parkin’s parents and family – Samuel did not receive the high level of care he should have had from us, and for this we are truly sorry.
“We have learned lessons and made important improvements to avoid this happening again – the coroner highlighted that St George’s has led the way in introducing changes that the wider NHS can learn from, such as enhanced training and improved communication between paediatrics and radiology teams. We have shared these with partners, including NHS England, Royal Colleges and trusts so that others can learn from this.”
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