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Boy's Hospital Ward Death 'Not Gross Failure'
A coroner has ruled there were "missed opportunities" in the care received by a four-year-old boy recovering from heart surgery.
Recording a narrative verdict, Avon coroner Maria Voisin found no "gross failures to provide basic care" for Sean Turner.
Sean, from Warminster, Wiltshire, was a patient on Ward 32 of Bristol Children's Hospital and died in March 2012 from a brain haemorrhage.
He had previously suffered a cardiac arrest, six weeks after he underwent corrective heart surgery.
Sean's parents Steve and Yolanda Turner, aged 47 and 45, told the inquest at Avon Coroner's Court how they pleaded with doctors and nurses to help him.
Mr and Mrs Turner accused doctors of transferring their son to Ward 32 from intensive care too soon and said they missed signs of his worsening condition, with rising blood pressure, vomiting and fluid loss from his chest.
His mother told the inquest: "Sean was deteriorating. We could see it but nobody listened to us.
"We asked so many times and so many staff - from ward doctors, outreach nurses, cardiac liaison nurse and the nurses - if Sean could go back to intensive care as he had been better there.
"We were told no beds or that simply he was not critical enough. Over four days Sean had increasing heart rate, was constantly being sick and was becoming so chronically dehydrated he was grabbing tissues used to cool his forehead and suck the water out of them.
"He kept asking for drinks but we were told he was on a fluid restriction to clear out his drains and this was normal procedure after a Fontan procedure."
After collapsing Sean was transferred to intensive care, where he remained for 11 days before being returned to the ward.
Mrs Turner described it as the "worst news" when they were told Sean was being returned to Ward 32 and the "beginning of the end".
She said nurses did not respond to automatic alarm calls on her son's monitoring equipment, did not complete regular fluid checks and did not fill in his record charts.
He suffered a cardiac arrest on February 16 and returned to the intensive care unit where he remained until he died on March 15.
Up to 10 families are believed to be taking legal action against the University Hospitals Bristol NHS Foundation Trust over treatment on Ward 32.
Ms Voisin said there were "lost opportunities" in the treatment of Sean but said this did not amount to a neglect verdict because there was not a gross failure to provide basic care.
Ms Voisin said she would not be writing to the hospital trust to recommend that changes are made to prevent future deaths.
"I am aware that the trust has made lots of changes since Sean's death and I do not consider that I need to make any report in connection with this matter," she said.
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