Baby death couple slam paramedics
The parents of a four-month-old baby who died after ambulance staff failed to treat her as an emergency said they still have "unanswered questions" over her death and are convinced she would still be alive if she had been treated "swiftly and competently".
Her mother, Emma Norley, 21, and father, Jhonny Poton, spoke out after a coroner recorded a narrative conclusion into the death of their daughter Lacey-Marie Poton.
The little girl collapsed just 10 minutes after returning home with her parents following a heart procedure at Bristol Royal Hospital for Children the previous day.
The inquest into Lacey-Marie's death follows others concerning babies and children who were treated at Bristol Royal Hospital for Children, amid allegations of neglect and mistreatment.
The couple said afterwards: "We still have many questions about Lacey-Marie's care at Bristol and the part played in her death by the failures we have heard about.
"We can only hope that this experience helps ensure that children receive better care at Bristol in the future.
"We will be instructing our legal team to obtain independent expert evidence so that we can assess what effect the failings we have heard about may have had on Lacey-Marie's final outcome.
"Despite attending a number of meetings with the Trust in Bristol, we did not receive any consistent explanation for our daughter's death.
"We are convinced that she would still be with us had she been treated swiftly and competently. We can only hope that no child has to suffer in the way she did."
The couple, who are expecting another baby shortly, added: "It is our wish that no other child has to experience what Lacey-Marie did and we want to feel confident that, wherever our new baby is cared for, it will be safe and looked after in the best and safest possible environment.
"The unit's patient safety record during the period of our daughter's treatment continues to be a concern and we know that this is something that the other families who lost children at Bristol during this time and are desperate to know more about."
What caused their daughter to collapse suddenly and die will remain a mystery as doctors have been unable to find out why, Avon Coroner Maria Voisin said.
Her mother performed CPR while an ambulance travelled to the property in Fishponds, Bristol in July 2013.
Paramedics arrived six minutes later and decided to take Lacey-Marie, who was "pale, mottled and floppy", to the hospital's emergency department.
The crew failed to recognise the baby's "time critical" condition so travelled at normal speed without blue lights or alerting hospital staff of their impending arrival.
Lacey-Marie's condition rapidly deteriorated after she reached Bristol Royal Hospital for Children and she died in her mother's arms about four hours later.
Her cause of death was recorded as complex congenital heart disease in Down's Syndrome.
An internal report by South Western Ambulance Service found "the crew did not recognise the time-critical nature of the baby and therefore conveyed the patient at normal road speed without a pre-alert to the hospital".
Paramedic Kevin Brown told the hearing he felt using blue lights may have only reduced the five-mile journey, which took 22 minutes and 19 seconds, by "one to two minutes".
Mark Lyttle, consultant in paediatric emergency medicine, said the hospital could have prepared experts, drugs and extra staff if it had received a pre-alert Lacey-Marie was coming.
Recording a narrative conclusion, the coroner said: "Lacey-Marie Poton was born on March 24 2013 and she had congenital heart disease and Down's Syndrome.
"On July 25 she became extremely unwell and was taken by ambulance to hospital where she died. The cause of her acute deterioration which led to her death is not known."
Ms Voisin said she had a duty to consider writing a preventing future deaths report but after hearing evidence of the changes the ambulance trust has made she said she would not be doing so.
Last year it was announced an independent review was to be held into the hospital's paediatric cardiac unit, which was to be led by Sir Ian Kennedy, a lawyer who specialises in the law and ethics of healthcare.
Up to 10 families are believed to be taking legal action against the trust over treatment on Ward 32.
Among them are Steve and Yolanda Turner, whose four-year-old son Sean died in March 2012 following complex heart surgery.
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.
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.
The South Western Ambulance Service NHS Foundation Trust said it had apologised to the family and the paramedic who treated Lacey-Marie had been placed under supervision.
"South Western Ambulance Service NHS Foundation Trust accepts the verdict given by the coroner," it said.
"All of our clinicians strive to deliver the best possible care, with the patient and their family's interests at the heart of everything they do.
"The Trust is very sorry that some elements of the care did not meet the high standards expected.
"The Trust fully investigated the care given to Lacey-Marie and Ms Norley accepted the Trust's apology and was satisfied with the remedial action that was taken in respect of this incident.
"The Trust has clear clinical guidance around when a hospital should be alerted that a patient is being brought in, a pre-alert, which should have been followed.
"The paramedic had on this occasion stated that they misunderstood the child's normal presentation, which may have influenced the decision not to pre-alert the hospital.
"Whilst it is exceptionally rare for such an incident to occur, the Trust has to ensure that all of our clinicians meet the high standards expected.
"As part of the investigation, the paramedic was restricted to working under the direct supervision of another experienced paramedic and received additional training and assessment.
"Only once we were assured that the issues had been fully addressed, did they return to full practice."
A University Hospitals Bristol NHS Foundation Trust spokesman said: "Lacey-Marie was diagnosed before birth with complex congenital heart disease and was treated several times at both St Michael's Hospital and the Bristol Royal Hospital for Children.
"Shortly before she died at the age of four months, Lacey-Marie underwent a cardiology procedure and was discharged home the next day after a thorough review by clinical staff.
"She returned to the emergency department later that day suffering from the symptoms of gastroenteritis but was not suffering from any complications as a result of her cardiac condition.
"After comprehensive clinical assessment and observation, clinical staff judged there was no need to admit her to hospital and she was discharged home.
"The coroner's independent conclusion is that the cause of Lacey-Marie's subsequent sudden deterioration is unknown but she made no criticisms of the care Lacey-Marie received at the Bristol Children's Hospital.
"We would like to reiterate our deepest condolences to her family."