Archie was a 1-year-old boy who tragically died on 23 November 2023, just 3 days after his first birthday.
Archie’s inquest was heard between 19 and 30 May 2025.
When Archie was born, he was considered health and discharged home. In the following weeks and months, Archie’s parents had concerns regarding this health and took him to seek medical help on no fewer than 16 occasions.
Archie’s medical cause of death was heart failure due to congenitally corrected transposition of the great arteries (ccTGA), a diagnosis only made after Archie’s tragic death. CcTGA is a rare heart defect in which the heart’s ventricles and great arteries are reversed, it is diagnosable with an echocardiogram.
The coroner heard expert evidence from Professor Anderson, Cardiac Surgeon, this evidence included that Archie had symptoms caused by his underlying heart pathology for months prior his death. Likely, from at least 9 September 2023.
On 5 October 2023, a possible heart pathology was considered, and a routine ECHO was ordered. The coroner found that there was an opportunity to undertake a more holistic review of Archie’s condition at this point, that might have led to a more serious consideration of a cardiac cause for Archie’s symptoms.
Archie attended the hospital again on 23 October, where he was again diagnosed with a viral chest infection and sent home.
Archie’s final admission started on 21 November 2023 for unresolving constipation. Archie showed signs of deterioration on 22 November 2023 through the evening and into the night. Archie declined into collapse, and despite resuscitation efforts, he died on 23. November 2023.
The coroner referred to “clear missed opportunities to adopt a proactive approach to diagnose [Archie’s] underlying condition”, she went on to say that Archie’s continued presentation was an indication to question why he kept attending. In her findings of fact she said, “there is no doubt that earlier recognition and diagnosis of Archie’s underlying heart condition would have altered the outcome” and “he almost certainly would not have died when he did”.
The coroner is currently considering whether to issue a prevention of future deaths report and has given East Kent Hospitals University NHS Foundation Trust two-weeks to provide documents regarding referrals and triaging.
Emily Raynor was instructed by Lily Hedgman of Leigh Day.
