Sean Turner Bristol hospital death: Blood monitoring 'not fully understand'

Sean Turner, four, was re-admitted to intensive care after suffering a cardiac arrest

A failure to monitor a boy's blood after heart surgery may have contributed to his death, an inquest has heard.

Four-year-old Sean Turner, who was from Wiltshire, died in March 2012.

He suffered a brain haemorrhage and cardiac arrest six weeks after he had undergone corrective heart surgery.

An expert told Flax Bourton Coroner's Court some Bristol Children's Hospital staff did not fully understand how blood clots should be dealt with.

Dr Ri Liesner, a haematologist at Great Ormond Street Hospital, said patients like Sean were at "high risk" of developing blood clots after surgery.

She said they should be given the drug heparin, which stops the blood from congealing, and that the clotting agents in the blood should have been monitored on a daily basis, something which was not happening on Ward 32 at the hospital.

The hearing was told when Sean's blood was being monitored, the readings were going in and out of a target range.

Dr Liesner said if a patient as "complex" as Sean, who was losing fluid from his chest and getting an infection, was treated at Great Ormond Street Hospital, she would have expected to have been consulted at an earlier stage.

She added that "on the balance of probabilities", he may not have developed the clot if he had effective anti-coagulation management.

However, she said his was a highly complex case with other contributing factors.

'Not exact science'

Doctors from Bristol Children's Hospital told the inquest that Sean was given the right dose of heparin at the right time.

They added that the administering of heparin was "not an exact science", but that they stuck to their own protocol in giving a certain dosage every day and that there are "other factors" in Sean's case.

The inquest heard that once the clot had developed, the four-year-old was given a clot-busting drug, which has the danger of causing bleeds, and it was this that caused the fatal bleed in Sean's brain.

The inquest has heard that following Sean's death, and that of seven-year-old heart patient Luke Jenkins, from Cardiff, who died nearly a month later, their parents complained to the independent healthcare watchdog, the Care Quality Commission (CQC).

The CQC performed an unannounced inspection and issued a formal warning to the hospital about standards on Ward 32, the specialist paediatric cardiac ward.

Sean's parents, Steve and Yolanda Turner, from Warminster in Wiltshire, have accused doctors of transferring their son to Ward 32 from intensive care too soon and said they missed the signs of his worsening condition.

Up to 10 families are believed to be taking legal action against the University Hospitals Bristol NHS Foundation Trust over treatment on Ward 32.

The inquest continues.