The family of a one-year-old who died in hospital have spoken of their heartbreak after a coroner concluded there had been “missed opportunities” in his care.

Archie Squire died just three days after his first birthday in November 2023 in the QEQM Hospital in Margate, with a lengthy inquest examining his death ending today.

In his short life, he visited A&E 10 times and was dubbed a “mystery child” by NHS staff.

One doctor broke down in tears during proceedings as he confessed the little boy’s death had changed his approach to work.

Concluding the inquest this afternoon, coroner Sarah Clarke said there were “clear missed opportunities to take a proactive approach to Archie’s care”.

While his mum and dad, Lauren Parrish and Jake Squire, have long maintained Archie would still be alive had doctors done things differently, they say the day-to-day impact of having lost a child while trying to raise youngest son Albie has hit hardest.

Speaking to KentOnline, the pair admitted they were left with dread at the prospect of Christmas, summer holidays and even laughing without Archie in their life.

Jake said: “It's stopped us wanting any more children. You just don't want to risk it again.

“I don't want to go on holidays or anything like that anymore because we should have been doing that together.

“It's just a massive hole, isn't it? You just can't be happy, and if you do, if you end up laughing or something like that, you feel guilty.”

Lauren added: “By the end of it, you want to cry, but there’s just nothing left to come out.

When asked what their ideal life would have looked like when they were 40, Lauren replied: “Four kids and a big house, holidays and things like that. We'd have a happy family.”

Having originally lived in Dover, the family have relocated to Margate since Archie’s death, haunted by life in a home that was made for a family of four.

“When we went back home from the hospital, it was like mind games. We could hear and see things,” explained Jake.

“Just being in the house was quite upsetting every day, we were so used to him running around.

“You go and look somewhere, you open something up and it’s something that he's just been playing with.

“Or you go on the telly, you go on to BBC iPlayer and it comes up with the last thing he was watching.”

Ms Parrish explained that Archie had struggled with symptoms including constipation, breathlessness, vomiting and "failure to thrive" - relating to him not gaining weight or growing as expected.

She first took her son to A&E in November 2022, shortly after his birth, when "grunting" noises he made in his sleep worsened.

Though he went on to visit the emergency department nine more times - being seen by several doctors, GPs and nurses - Ms Parrish said medical professionals described Archie as a "mystery child" as they could not establish what exactly was wrong with him.

An echocardiogram - an ultrasound of the heart - was ordered on October 6, 2023, but was not done within two to three weeks as was advised.

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

Concluding the inquest at Oakwood House, Maidstone, on Friday afternoon, Ms Clarke said it was not her place to place any blame or liability.

The coroner the court: “I do not agree that the evidence suggests a lack of training, instructions, or guidance is apparent.

“I agree entirely since Archie’s death, a significant investigation and reflection has taken place at many different levels, and that we have heard about new and, one hopes, more robust systems that are to be put in.

“[But] there were clear missed opportunities to take a proactive approach to Archie’s care.

“There is no doubt that earlier recognition and diagnosis of Archie’s underlying heart condition would have altered the outcome.

“There are many points in the chronology I could say were missed opportunities to do something differently.”

Addressing the family directly, the coroner added: “You are an absolute credit to each other, you have supported each other outstandingly through this process and it is not an easy process to go through.

“I can absolutely assure you, from my point of view and the entire coroner service, we will never forget Archie.”

A leading surgeon told the court yesterday how Archie’s condition was a “one-in-35,000” case that many doctors may only come across once in their careers.

However, Professor David Anderson confirmed his belief Archie was not treated soon enough – with particular emphasis on an echocardiogram not being done in an appropriate time weeks before he died.

Last week, Doctor Ravindra Kumar, a paediatric registrar at QEQM responsible for Archie on the night he died, broke down in tears in court, describing how his work has changed since Archie’s death.

Asked what he would do differently, Dr Kumar said: “I regret talking about Archie’s condition in front of the family to others, to my colleagues. I learned a big lesson to be more compassionate.”

Wiping tears from his eyes, he told the court: “We discussed the child’s condition in a manner as if parents did not exist in the room.”

Having been thrust into the limelight, the naturally reserved Lauren and Jake have found themselves at the centre of a very public affair.

It has seen them contacted by countless families in the same position, all of whom are lobbying for healthcare workers to take parents' concerns more seriously.

Lauren said: “I know they're professionals, but we're with our children every day, they don't see the stuff that we see, and when you're trying to explain it to them, it's just like they're just seeing what they see.

“They just need to be more understanding that we know best, really, because we know what's right for our children and what's wrong, because we see them every day.

“If you look at the bigger picture, they all played a part in their own way.

“We just can't get that night out of our head, but then when we look back now, it wasn't just that night. They've messed up more than just the one night.”

Bosses at EKHT referred to a number of changes it had made following a review triggered by Archie’s death and apologised for its role in the tragedy.

Chief executive Tracey Fletcher said: “We offer our sincere condolences to Archie’s family. We can only imagine the pain they have endured and we are truly sorry that we did not identify Archie’s condition earlier.

“After meeting with Archie’s family, we have made important changes to our service.

“These include one standard process for triage and booking of child referrals, and prioritising the assessment of children referred to us. We will examine further learnings identified through the inquest process.

“Staff across the trust now receive specialised training to improve how clinical concerns, diagnoses and plans are discussed with families in our care. The training for our children’s health team specifically draws on lessons learned from Archie’s death.”

There is now a new standardised process for triage and appointment booking in all specialities within children’s health, including cardiology, and improvements to the system of review for children with multiple attendances to A&E.

Teaching and simulation experience has been drawn up directly on Archie’s experience, including a focus on rare cardiac conditions and compassionate communication with families.

Updated guideline for the ‘Recognition of Faltering and Atypical Growth in Infants and Children’ measures now ensures that all children who are referred with faltering growth are seen urgently and emphasises the consideration of cardiac concerns.