The mother of a young boy who died following heart surgery begged doctors and nurses to help her desperately ill son, an inquest heard today.
Sean Turner died in March 2012 at Bristol Children's Hospital from a brain haemorrhage after previously suffering a cardiac arrest - six weeks after he underwent vital corrective heart surgery.
The four-year-old's parents, Steve and Yolande, from Warminster, Wiltshire, blame staff shortages and lack of training on Ward 32 for his death.
Giving evidence on the first day of the two-week hearing at Avon Coroner's Court, near Bristol, Mrs Turner said: "I remember going into the corridor and seeing Sean being pushed in his bed and he looked at me and called 'Mummy'.
"We will never forget the days on Ward 32 and can never understand how a child can be left to suffer for so long.
"How was this supposed to be a specialist cardiac unit in a centre of excellence, yet no one recognised Sean's deterioration? His arrest was preventable because all the signs had been there.
"Events on Ward 32 dashed Sean's chances of survival. And, as found in his death review, a femoral line causing sepsis and clots, sub-optimal recognition of a deteriorating child, sub-optimal nursing staffing and sub-optimal communication had all contributed to his death.
"This is wholly unacceptable."
Mrs Turner said that she felt Sean was moved from the intensive care unit to Ward 32 too soon after his operation on January 25 - remaining there for just 18 hours.
"When he was transferred off the intensive care unit we felt he was not well enough and had been told he could spend up to four days there," she said.
"When we asked why he was being moved so soon, we were told that the bed was needed in intensive care."
The inquest heard that after three days on Ward 32 Sean underwent further surgery to remove a build up of fluid around his heart and was returned to the ward.
Mrs Turner said that she questioned why her son was taken back to Ward 32 and was told he was being cared for in a high-dependency bed.
"Sean was in a lot of pain with three chest drains and was only on paracetamol. We asked if he could have something else and was told he could only have tramadol as he was being sick.
"Following the tramadol Sean had his first very frightening collapse. He said 'Mummy, I don't feel well' and his skin went mottled and his blood pressure dropped very low.
"This was very scary for us and seemed to take several hours before he was stable enough to be returned to intensive care.
"Over the 11 days in intensive care Sean made progress. He was even getting out of bed with physio's help."
Mrs Turner said that straw-coloured fluid continued to drain from her son's chest, which she said had concerned doctors as it was "extremely high".
Mrs Turner described it as the "worst news" when she was told Sean was being returned to Ward 32.
"Steve and I were not happy and asked that Sean remain in intensive care. We were told that Sean was not critical and was taking up a bed for a critical child," she told the hearing.
"We said the last time Sean went to Ward 32 he collapsed and now he's improving. We were again told that Sean was in a high dependency bed and his needs could be met there on Ward 32.
"This move to Ward 32 from the safety of intensive care was to the worst decision ever made for Sean."
Fighting back tears, Mrs Turner added: "And as we now know with the inadequate staffing levels and no high-dependency care, this was the beginning of the end for Sean."
Mrs Turner said that when Sean's oxygen levels fell below 85% an alarm would sound on a monitor next to his bed on Ward 32.
"Nurses would come in and silence the alarms and not do anything. They showed us how to silence the alarms and we wanted to know why it was happening but they did not seem to know," she told the inquest.
Mrs Turner said the nurses were not doing regular fluid checks and did not fill in his record charts.
"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," Mrs Turner said.
"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.
"This was not normal, our little boy was switching off, in terrible pain, struggling to breath and had an increasing heart rate at times, higher than 150.
"Sean kept telling us he did not like it and was in pain. There was no proper management of his pain.
"We tried so hard to get him some help and kept asking the cardiac liaison nurse to speak to doctors for us.
"Nothing happened, nobody seemed to help. Nurses were concerned but they seemed too busy to give the time needed to care for Sean at the level he needed.
"Every nap he had I sat and cried as I felt so desperate and so helpless. Why would no one listen?"
Mrs Turner said that whenever Sean's monitoring alarms went off there was never a nurse around.
"It felt like Steve and I cared for Sean ourselves over those four days," she said.
Mrs Turner had gone for a short break and a drink when Sean suffered his cardiac arrest on February 16 and rushed to his bedside to be with him.
The inquest heard that the little boy was then transferred back to the intensive care unit where he remained until he died on March 15.
Mrs Turner said that following the cardiac arrest the family's request for a second opinion from a retired consultant at Great Ormond Street Hospital was refused by doctors in Bristol.
"We felt helpless because we were desperate for some answers and a way forward for Sean. We wanted to have Sean transferred but were told that he was too poorly to be moved," she said.
"We felt our lifeline of a second opinion had been taken away from us.
"Sean fought so hard in hospital. There were so many missed opportunities to rescue Sean from the desperate state he was in.
"We now know that after Sean suffered the cardiac arrest he should have been taken into theatre - Sean stood a chance.
"But taking the approach to 'wait and see' if Sean would get better by himself cost him his life. All we can do now is put our faith in this court to find the truth."
Mr and Mrs Turner claim their son's death was not isolated and other children with heart problems died at the hospital.
Up to 10 families are believed to be taking legal action against the University Hospitals Bristol NHS Foundation Trust over treatment on Ward 32.
In November last year, Avon Coroner Maria Voisin recorded a narrative conclusion at the inquest of Luke Jenkins, seven, who died in April 2012 following surgery there.
Following the coroner's conclusion, Luke's mother Faye Valentine, 28, said she believed the hospital could have done more to save his life.
Miss Valentine, from St Mellons, Cardiff, claimed Ward 32 was understaffed and accused doctors and nurses of ignoring her concerns.
The coroner ruled she had not heard evidence of "gross failures" in Luke's care and recorded a narrative conclusion, ruling that he died from a combination of hypoxic ischemic brain injury, post-operative bleeding and a congenital heart defect.
"Whereas Luke was in a dependent position due to age and illness, I have heard no evidence that a gross failure has led to or contributed to his death," she said.
Two more inquests involving the hospital are scheduled for February and March.