The coroner in the inquest into the death of Sean Turner at Bristol Royal Hospital for Children has retired to consider her verdict, after hearing evidence from the final two witnesses today.
Avon coroner Maria Voisin is expected to deliver her verdict on the death of the four-year-old, from Warminster, at Flax Bourton Coroner’s Court tomorrow.
In his final submission, Adam Korn, the barrister representing the Turner family, invited Ms Voisin to deliver a narrative verdict, but also asked her to make a Prevention of Future Deaths report.
Mr Korn said Sean’s family believe there were failings on a haematological level and a surgical level, but that the threshold to find neglect had not been passed during the inquest.
Louise Wiltshire, representing the University Hospitals Bristol NHS Trust, also recommended a narrative verdict, but she added that there was insufficient evidence to suggest a report should be made.
Sean died in March 2012 from a brain haemorrhage after previously suffering a cardiac arrest - six weeks after he underwent vital corrective heart surgery at the hospital.
His parents, Steve, 47, and Yolanda Turner, 45, have given harrowing accounts to the inquest of how they begged doctors and nurses on Ward 32 to help their desperately ill son.
The inquest heard today from Dr Duncan Macrae, a consultant in paediatric intensive care at Royal Brompton Hospital, who was instructed by Ms Voisin to provide an expert report.
Dr Macrae told the inquest that the fluid losses Sean suffered after he underwent Fontan surgery to help his heart work more efficiently were among the highest he had ever seen in a child.
He said: “It was appropriate to consider Sean a low risk case for Fontan surgery, so it was surprising he developed such persistent chest drain losses post-operation.”
Ms Voisin asked Dr Macrae whether Sean was fit to be moved from the Paediatric Intensive Care Unit (PICU) back to Ward 32 on February 9.
Dr Macrae said: “His ongoing care requirements around that time were relatively high because he had high chest drain losses.
“He needed high dependency care, which I take to be one nurse to look after two patients. I was not sure that's what he received on Ward 32 but that's what he should have received.”
Dr Macrae said that from February 12 Sean's condition was beginning to deteriorate - with rising heart rate, vomiting and nausea - and he should have been seen by a cardiac consultant.
He said: “I think it would have been appropriate for there to have been a review by a consultant cardiologist in the first instance and obtain an echocardiogram to exclude a cardiac tamponade (fluid on the heart).
"If the right people had been there and asked the right questions he could have been moved to the paediatric intensive care unit or had an echocardiograph done, which might have led to more thought and steps taken to his improve his condition.”
Avon Coroner Maria Voisin asked Dr Macrae whether the cardiac arrest was preventable, to which he replied: “I believe it was. I cannot see any link between the cardiac arrest and Sean's chest drain losses.”
He added that fenestration - a follow up surgical procedure that makes a hole between the Fontan tunnel and the heart - may have reduced the losses but would not have stopped them completely.
Mr and Mrs Turner believe blood specialists, called haematologists, were not as hands-on as they should have been with their son’s care.
The inquest previously heard that Sean was given the drug heparin to try and prevent blood clots from forming - a common occurrence in heart surgery patients.
Dr Macrae, when asked whether he would have consulted haematologists, told the inquest: “In my own practice, I would consult a haematologist as in Fontan circulation a large clot is a major complication.
“It would be important to pull all the stops out to dissolve that clot and allow fenestration to take place, although that is not under taken lightly in a patient that had just had surgery.
He added: “My hunch is that early fenestration would have helped the chest drain losses and would have reduced the chances of clot formation.”
The inquest also heard from Dr Patricia Weir, who is a consultant in paediatric anaesthesia and intensive care at Bristol Royal Hospital for Children.
Mr and Mrs Turner claim their son's death was not isolated and other children with heart problems have died at the hospital, including Luke Jenkins, aged seven, from Cardiff.
Up 10 families are believed to be taking legal action against the University Hospitals Bristol NHS Foundation Trust over treatment on Ward 32.
The hearing was adjourned until tomorrow.