A 16-year-old boy who died after suffering a cardiac arrest caused by an undiagnosed bowel condition would likely have survived if St George’s Hospital had correctly diagnosed his symptoms, a coroner has ruled.
Samuel Finlay Parkin, who had suffered episodes of vomiting and abdominal pain since childhood, died in September 2022 from complications of a congenital condition called malrotation. The disorder caused a twisted bowel — known as a volvulus — which cut off blood supply, ultimately leading to a brain injury and cardiac arrest.
A Prevention of Future Deaths (PFD) report [pdf] issued by Assistant Coroner Ellie Oakley in January 2024, but only published last week, concluded that clinicians at St George’s gave false reassurance based on ultrasound results that could not rule out the condition. Despite repeated hospital visits over nearly a decade, no further imaging or surgery was pursued: a failure the coroner concluded led directly to his death .
The delay in publishing the report appears to reflect procedural norms: after issuing a PFD report, coroners must wait for formal responses from the NHS and involved trusts, which are then reviewed by the Chief Coroner before public release.
A rare but deadly oversight
Samuel had been seen multiple times at St George’s Emergency Department from 2013 onward, as well as in outpatient clinics. Although a possible diagnosis of malrotation was raised once in 2015, the correct diagnostic imaging — a barium contrast study — was never performed. An ultrasound was instead used, even though this test cannot definitively rule out malrotation.
St George’s later admitted that the inclusion of a note in the 2015 ultrasound report stating that a particular anatomical axis appeared normal gave “false reassurance.” Experts told the inquest this led to a missed opportunity for surgical intervention that could have saved Samuel’s life .
Systemic failings and delayed learning
The coroner identified multiple failings, including inadequate communication between hospital departments, reliance on inconclusive imaging, and poor safety-netting advice to Samuel’s family. She warned that similar deaths could occur unless NHS-wide action is taken.
In response, St George’s said [pdf] it has lowered its threshold for ordering contrast studies in children with recurring abdominal symptoms, introduced monthly multidisciplinary meetings, improved referral documentation, and committed to sharing learning nationally.
NHS England also pledged action [pdf], including updating its national service specification for paediatric gastroenterology and revising guidance on second opinions and multidisciplinary discussions.
The coroner warned that similar deaths could occur unless NHS-wide action is taken.
National and local context
Samuel’s death is one of hundreds now being scrutinised under the coronial system. National figures show a sharp rise in Prevention of Future Deaths reports: 297 were issued in 2020, rising to 476 in 2021, 409 in 2022, 558 in 2023, and 706 in 2024. So far in 2025, 385 reports have been published.
Despite this surge, St George’s has only been named in two such reports over the past 12 years, with the previous one dating back to 2020. However, questions about its internal systems remain. In April, Putney.news reported on how a senior emergency nurse at the hospital had been suspended for a year following a series of serious incidents, and last month that the Trust has yet to disclose what it knew and how warning signs were missed. That case has prompted further scrutiny of oversight and transparency at the hospital.
Broader lessons
Samuel’s case is now being cited at national clinical conferences and will inform NHS-wide training and diagnostic standards. Coroner Oakley has also sent her findings to health authorities across the UK, including NHS Scotland, NHS Wales, and the Royal College of Paediatrics and Child Health, in an effort to raise awareness of malrotation and prevent future deaths .
Samuel’s family have not spoken publicly about the inquest findings. St George’s says it remains in contact with them and is committed to learning from what happened.
This case was first covered by Local Democracy Reporter Charlotte Lillywhite.
