An “always smiling” baby was taken to A&E more than 10 times with a “missed” heart condition before suffering fatal cardiac arrest, an inquest is expected to hear.

Archie Squire, from Dover, was repeatedly rushed to Margate’s QEQM in his first, and only, year of life after suffering constipation and breathlessness.

But his parents Lauren Parrish and Jake Squire, say he was discharged on several occasions diagnosed with the common respiratory infection bronchiolitis.

During five hospital visits between August and November 2023. medics missed the fact the “happy and always smiling” child suffered an undiagnosed and extremely rare heart condition.

An East Kent Hospitals Trust (EKHT) investigation into the death, ordered by the coroner, found there were “missed opportunities” to recognise an “abnormal cardiac shadow” on X-rays.

As Archie rapidly deteriorated he was placed in the care of Rainbow Ward on November 21 due to constipation and vomiting but his condition worsened the following day after receiving treatment via a tube.

Within the space of four hours early on November 23, he entered cardiac arrest twice – with CPR successfully bringing him back once.

However, the second arrest proved to be fatal with Archie’s time of death given as 5.28am.

At a pre-inquest review looking into Archie’s death at Oakwood House in Maidstone today (Aug 1), coroner Sarah Clarke set out her plan for the upcoming months.

She said: “An inquest is a fact-finding mission. We’re not pointing the finger, we’re trying to bring about change.

“How Archie came by his death is a little more complicated.

“I don’t want to delay the inquest being heard.”

A second pre-inquest review is to be scheduled for October 24, with coroner Clarke hoping to see proceedings not spill over into 2025.

She told the family: “I would hope we’d be looking at a full inquest by the end of the year.”

A paediatric oncologist from St Guy’s Hospital will be drafted in as an expert to assist the court in its probe.

It was noted statements required from East Kent Hospitals Trust workers were still outstanding, with the coroner aiming to have all evidence together by September 2.

The family said after the review: “We are relieved that the inquest process into Archie’s death is underway.

“As a family, we have a number of questions about the care and treatment Archie received in his all too short life and we trust the coroner to carry out a full and detailed investigation.”

Between August and November 2023, Archie was brought to QEQM five times, where his breathing issues were documented as bronchiolitis.

Although it was noted in the report there was a need to “exclude cardiac cause” due to “sudden bouts of sweating and breathlessness after feeds” during an October visit.

However, this was neither requested nor triaged as urgent and was due to take place six to eight weeks after his discharge.

A post-mortem revealed the heart failure was caused by isolated cardiac ventricular inversion, where the left atrium enters the right ventricle and vice-versa.

A comprehensive 89-page report prepared for Archie’s inquest highlighted a failure to consider a wider diagnosis beyond bronchiolitis – a condition Archie had been diagnosed with.

Faults were also found with delays in accepting GP referrals, inconsistent documentation, and reviewing previous clinical papers.

Investigators wrote in their report: “There was a delay in recognising in a timely manner, Archie’s clinical deterioration.

“Archie’s referral was not marked as urgent, however, any GP referrals mentioning faltering growth should be either booked in a rapid access clinic or for an urgent paediatric review, or changed to an urgent referral.

“There is no evidence that this differential list (on clinic letter, EDN and careflow) followed Archie through his subsequent admissions, therefore resulting in missed opportunities to diagnose him appropriately.

“There was also no evidence of a robust follow-up plan in the context of faltering growth nor where the family can seek help if they have further concerns.

“There were inconsistencies in the quality of documentation of reviews, investigation findings and response to treatment given.

“Although we recognise his symptoms of cardiac disease were subtle we believe had a broader differential diagnosis in the context of faltering growth been considered and communicated effectively he would have been investigated further.”

Thirteen recommendations were subsequently made, including to “provide more compassionate care and behaviours training to enhance care received after child deaths”.

Ms Parrish, Archie’s brave mother, previously told KentOnline the recent findings devastated her.

“The investigation is just so ongoing and demanding, you don't get time to grieve,” she said.

“Everything's just constant, meeting after meeting with the hospital and waiting for reports to come back has taken ages,” she said.

“Some families wait for years, it’s too long – it needs to be much quicker.

“My first reaction to the report is they’ve messed up big time, and things happened that we were never even told about.

“Everyone we know is just shocked and devastated at everything that's gone on because you wouldn't think taking your son to hospital for what we did that he wouldn't come back out again.

“But I would say the investigating team that we had were really good, they were quite thorough, they went in detail and found loads of stuff that we weren't even aware of, so I can't fault them at all.”

Archie – who “shut down Margate” at his funeral – was described by mum Lauren and dad Jake Squire, both of Dover, as a “happy little lad who was always smiling”.

An older brother to Albie, the toddler was also “a real daddy’s boy” and was part of a family which spanned five generations.

While Archie’s pre-inquest review has been provisionally pencilled in for August 1, a date for the full probe is yet to be confirmed.

Sarah Hayes, chief nursing and midwifery officer at the trust, said: “Our hearts go out to Archie’s family and we are so sorry for their devastating loss.

“We will do all we can to support Archie’s family and the coroner’s investigation.”