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A three-year-old boy died after a new NHS computer system failed to schedule him for a "vital" scan, a coroner has ruled.
Samuel Starr suffered with a congenital heart defect and was due for a scan nine months before an operation, but due to a new computer system at Royal United Hospital in Bath, it was twenty months before he was.
Samuel's parents are now considering legal action following the three-day inquest into his death. ITV News' Medical Editor Lawrence McGinty reports.
A Coroner has recorded a narrative verdict into the death of toddler Samuel Starr, after a computer failure led to the boy's death.
Concluding a three-day inquest at Flax Bourton Coroner's Court in North Somerset,Avon Coroner Maria Voisin said: "Samuel Starr was born with a complex cardiac disease.
"He required surgery and regular check-ups at outpatients to manage his conditions.
"Due to the failure of the hospital outpatients booking system, there was a five month delay in Samuel being seen and receiving treatment.
"Samuel's heart was disadvantaged and he died following urgent surgery."
A three-year-old heart patient died after a new NHS computer system "failed" to schedule him for a vital hospital scan - leading to a delay in his treatment, a coroner has ruled.
Samuel Starr, who was born with a congenital cardiac defect, underwent surgery not long after his birth in 2010 and made a good recovery.
However, medics said he would still need regular tests to check on his progress at Bath's Royal United Hospital.
But a delay came after a new computer system, called Cerner Millennium, was rolled out and Samuel did not have a crucial scan for 20 months after his first major operation.
When he finally had the appointment, doctors found Samuel needed open heart surgery. During the procedure, Samuel suffered a stroke.
Further complications followed and he died in the arms of his devastated parents, Catherine Holley and Paul Starr, a month later.
Avon Coroner Maria Voisin today, recording a narrative conclusion, ruled the booking system meant Samuel was not seen and did not receive treatment.