Hampshire & Isle of Wight

Southampton out-of-hours nurse criticised over boy's death

Sam Cutler
Image caption Sam Cutler died three days before his 13th birthday

A coroner has criticised an NHS out-of-hours service nurse who told a boy's mother she should wait 13 hours to see a GP days before he died.

Sam Cutler, 12, who had a rare heart condition, was probably seriously ill on 9 May last year, his inquest in Southampton heard.

Coroner Keith Wiseman said nurse Gary Richards should have taken "a safety first approach".

Solent NHS Trust said it would look in detail at the coroner's findings.

The inquest was told the schoolboy had a rare congenital heart condition which meant all his organs were in the opposite position to what they should be.

'Individual failure'

GP Abdul Shahid saw Sam the next morning and immediately arranged for him to go to hospital.

The doctor was critical of the advice given by the out-of-hours service because notes he received said Sam should have been seen within six hours.

The inquest heard Sam, of Maybush, had had three major operations in his life which had left him with an increased risk of contacting endocarditis - which presents a wide-range of symptoms, including fever and confusion.

He was diagnosed in hospital but on 17 May he died from a sudden clot, three days short of his 13th birthday.

A review by Solent NHS Trust found that Mr Richards' actions had "fallen significantly short" during the telephone conversation with Mrs Cutler.

The report concluded the failure was individual and not organisational.

The senior nurse received a formal warning and was told to retrain, the inquest heard.

Recording a verdict of natural causes, Mr Wiseman said that, "on a balance of probability", Sam's symptoms "must have been present" when the out-of-hours service spoke to the family.

"The extent of further significant deterioration between Sunday evening and the Monday morning is unclear, but obviously the earlier treatment can be given the more chance there must be of the recovery of the patient.

"The extra vulnerability of a child with a significant congenital condition demands a safety first approach."

Solent chief executive Dr Ros Tolcher said: "We will be looking in detail at the coroner's findings to establish how we can make further improvements to our services."

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