“St George's have noted a number of learning outcomes in the course of their M&M process…”

The coroner’s concerns

1. St George's have noted a number of learning outcomes in the course of their M&M process and the Child Death Analysis Form. Whilst I heard evidence of training and informal discussions amongst colleagues both at St George's and regionally, I consider that action is required to ensure that those learning points are formally considered and disseminated throughout St George's and more widely in the NHS. 2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation. The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis was normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam's death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance. St George's has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children, and to avoid any similar confusion regarding the reporting of USS both in St George's and across the NHS. 3. Following Sam's death, St George's has reduced the "threshold" for requesting of upper GI contrast studies in intermittent abdominal pain and intermittent vomiting. Given the serious nature of the potential risk that malrotation carries (namely of volvulus occurring) I consider action is required across the NHS, following St George's lead, to ensure that the symptoms of and diagnostic tests for malrotation, particularly in older children is understood. Where the learning in St George's is informal, I consider action is required to ensure that formal learning takes place within St George's. 4. St George's has implemented a change in `safety netting' advice for those with what is thought to be benign abdominal conditions from Paediatric ED (using QR codes), from wards and outpatient clinic. Advice is give in writing that "benign abdominal diagnosis" does not exclude conditions requiring urgent surgical/ medical review. This action has been taken for the reasons set out above and action should be taken to ensure the wider NHS considers this learning point. 5. One of the learning actions taken by St George's is that re-referrals to gastroenterology are reviewed by another consultant in order that a fresh assessment/second opinion may occur, followed by an MDT discussion and the option of transferring back to the original consultant. St George's feels this may help increase the detection of atypical/unusual presentation of GI conditions, including a later presentation of malrotation. Action is required so that this learning point is considered across the NHS. 6. The evidence before me suggested that there may have been a miscommunication or misunderstandings between the surgical, paediatric and paediatric gastroenterology teams regarding what had and had not been considered and excluded by each during Sam's admission in 2015. In particular, St George's written answers to Mr and Mrs Parkin's question regarding whether there was miscommunication between the treating clinicians was simply "yes". St George's has therefore implemented an inpatient (written) referral form to the GI service. Action is required by St George's and the wider NHS to consider/implement ways to minimise the possibility of miscommunication between teams/in referrals of all disciplines.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0361

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0