On Tuesday 19 April 2011, Mr Keith Wiseman, HM Coroner for Southampton and New Forest at Southampton Coroner's Court recorded a verdict of Natural Causes at the Inquest into the death of Sam John Richard Darren Cutler.
Mamta Gupta, a practising barrister at No5 Chambers who specialises in cases of clinical negligence and personal injury, was instructed by Laura Vaughan of Southampton-based Trethowans Solicitors to represent Sam's parents, Andrew and Linda Cutler, at the Inquest.
Sam from Maybush, Southampton, died on 17 May 2010 at Southampton General Hospital only three days before his thirteenth birthday. A post mortem examination which was conducted on 20 May 2010 determined that the three causes of Sam's death were Right Ventricular Thrombus, Fulminant Infective Endocarditis and Complex Congenital Heart Disease.
Sam and his mother had sought advice from a General Practitioner at Regents Park Surgery, Southampton on 6 May 2010 when Sam had been suffering from vomiting and diarrhoea. Sam's parents were worried about his illness because Sam had suffered from a complex heart condition since birth but Sam's mother was reassured by the doctor that Sam was only suffering from a gastric bug that was doing the rounds at that time.
When Sam's condition worsened, Mrs Cutler telephoned the West Hampshire Out of Hours Service at approximately 6.30pm on Sunday 9 May 2010 in order to seek further advice and spoke to Gary Richards, a Clinical Nurse. Although Mrs Cutler explained that Sam was not drinking, was lethargic and was getting confused and although she informed the Nurse that Sam had a heart condition, he did not arrange for Sam to be examined that evening and instead advised Mrs Cutler to take Sam to see his GP again the following day.
By the time that Sam's usual GP examined Sam at approximately 9.00am on 10 May 2010, Sam was severely dehydrated and was immediately admitted to Southampton General Hospital as an emergency.
He was diagnosed with Infective Endocarditis, inflammation of the inner tissue of the heart caused by a bacterial infection, and died at the Hospital a week later.
The two day Inquest was opened to investigate the cause of the death of the former Redbridge Community School pupil on 29 March 2011. HM Coroner heard oral evidence from the health care professionals involved in Sam's care.
These included the Pathologist who performed Sam's post mortem; two General Practitioners from Sam's GP surgery; the Consultant Cardiologist from Southampton General Hospital who had cared for Sam since birth; two representatives from West Hampshire Out of Hours Service including the Clinical Nurse who took Mrs Cutler's call on 9 May 2010 and a Consultant in Paediatric Intensive Care who had been involved in Sam's care in the last few days of his life at Southampton General Hospital.
During the Inquest, the Coroner also read aloud the transcript of the telephone conversation between Mrs Cutler and the West Hampshire Out of Hours Service on 9 May 2010.
The verdict given today by the Coroner was that the cause of Sam's death was Natural Causes. However, the Coroner gave a narrative verdict in which he said that on a balance of probability the clear symptoms of Sam's Endocarditis may well have been present by the time of parental contact with the Out of Hours Service on the evening of Sunday 9 May 2010. Mr Wiseman said that obviously the earlier treatment can be given the more chance there must be of the recovery of the patient. Mr Wiseman concluded by saying the extra vulnerability of a child with a significant congenital condition demands a safety first approach.
On hearing the Coroner's verdict and comments, Sam's mother, Linda Cutler said; "I believe that the Clinical Nurse that I spoke to from the Out of Hours Service should have arranged for Sam to be seen straight away. Sam was very ill and I believe that those precious few hours could have made a difference. We cannot bring Sam back but we can try and make sure that no other mother or family has to go through the same situation again by making people aware of the failings that took place in Sam's case."
Laura Vaughan said today; "The Coroner heard a great deal of oral evidence during the two day Inquest in March 2011. It was very important to Sam's family that a full investigation of the medical advice and treatment which Sam received during the last days of his life was properly conducted so that all of the relevant facts could be put before the Coroner.
It is also important to Sam's family to raise public awareness of their experience of West Hampshire Out of Hours Service and the deficiencies in the channels of communication between that service and local GP surgeries. They want to try to do everything in their power to prevent any other family ever experiencing the same tragedy."
Mamta Gupta added: "Sam's family are concerned that the GP who saw Sam on 6th May 2010 neither took account of their son's congenital heart problem nor the fact that he clearly was not keeping his daily medication down, which is alarming, given the increased risk of infection.
Mr & Mrs Cutler trusted both the doctor and Nurse Gary Richards and acted as they were advised by the Health Care Professionals."
In the light of the Coroner's Verdict and the evidence heard at the Inquest, Mrs Cutler and her family will now be receiving advice from Trethowans Solicitors and No 5 Chambers regarding the possibility of taking legal action against the health care professionals who were involved in Sam's care before his death.