Samuel Starr: 3-year-old dies after NHS computer system error

4 March 2014

Samuel Starr: 3-year-old dies after NHS computer system error

An inquest has heard how Samuel Starr, three, died following after a vital hospital appointment was delayed for 20 months because of a glitch in a new NHS computer system.

Samuel was born with a congenital heart defect having surgery at Bristol Royal Hospital for Children at 9 months old. After making a good recovery he was due to attend follow-up appointments at Bath's Royal United Hospital (RUH).

Computer system glitch

An inquest at Avon Coroner's Court heard how a new NHS computer system which managed his appointments made an error which meant that Samuel did not have a crucial scan for a full 20 months after the major operation. The computing system was introduced at the RUH in 2011 and only after an appointment was later set did doctors find that Samuel needed urgent open heart surgery due.

The resulting delay and exacerbation of the heart condition and blockage of blood vessels heightened the risk of further complications and which proved fatal in August 2012 when Samuel eventually suffered a stroke and passed away.

"He died in our arms"

Speaking at his inquest, his mother Catherine Holley said she expected Samuel to get a check-up and scan in early 2011 and was "alarmed" when the appointment did not actually happen until the summer of 2012. The appointment booking system-called Cerner Millennium-managed Samuels’ appointment schedule and errors within its systems meant the crucial follow up was delayed.

Ms Holley said 'He was a kind and gentle boy with a great understanding of the world. As we read Samuel his favourite stories, he died in our arms.'
Reading a statement, she added: 'We were expecting an appointment in the New Year (2011) - something we took to mean January - but we still hadn’t received one by March.

'We got Claire, our community nurse, to call the hospital. She called them on the 12th March, 20th March, 8th May, 28th May and the 29th May.

'We were then given an appointment for 14th June but we already had commitments then so it was rescheduled for 21st June.

Crucial follow up delayed

'When we got there Dr Tometzki said that he had expected to see us a lot earlier than this.

'After doing an echo scan he told us he didn’t want to shock us but he wanted Samuel to have heart surgery that spring.

'We were shocked, we hadn’t been expecting this. It wasn’t meant to happen.'

Samuel had a cardiac catheter inserted in July, before undergoing surgery in August.

'Just hours before his operation Samuel was dancing around the ward and telling the nurses all about Spiderman - we had to remind him to quieten down,' Ms Holley said.

"He was a happy and healthy boy"

'Many of the nurses on the ward could not believe how energetic he was considering the surgery he was about to have - he was a happy and healthy boy.

'After the operation, on August 9, as they began bringing Samuel out of sedation his left arm started flailing. 

'We were (later) told Samuel had had a stroke and several cardiac arrests.'

After the first surgery in March 2010 Samuel was referred to the Paediatric Cardiac Clinic at the RUH for check-ups and after the first appointment took place in October 2010 to carry out heart tests, the next appointment in April 2011 involved no heart echo tests at all.

The inquest continues. has specialist departments which deal with enquiries relating to paediatric care and cardiac related conditions. was created to listen to talk to people who feel that they had nobody at the NHS to listen to them when something went wrong. Members of the public who call through to us often want to raise an issue within NHS care so that somebody else is not affected the way their and their loved ones have been. Sometimes they call through to us to make a medical negligence claim because a financial settlement is needed to rebuild their life and to take care of their family. If you have experienced a form of medical mistreatment through emergency services, A&E or through surgery, for example, you can speak to the experts at