The parents of Jack Tually have reflected on what they have called "harrowing failures" that led to his death.
In a statement, they spoke of their continued grief, and called on the government and health officials to learn from this case and introduce better processes.
No family should ever have to wait so long for answers, a wait which has only served to compound our grief. There is clearly a need to reform the coronial process to ensure that it operates more transparently and efficiently. The expert evidence recorded a litany of harrowing failures in midwifery, obstetric and paediatric care as well institutional failings in clinical care, management and governance. We will always feel those failings in care, whether individually or collectively, contributed to the loss of our beloved son. The expert evidence at the inquest confirmed that Jack’s condition could have been survivable had he received proper treatment. None of the doctors admit these failings identified by their peers/experts. It is impossible to see how the public interest could be served, or health services improved, in the face of such arrogance. We can only hope that Guernsey’s politicians, senior health officials and individual clinicians take heed of Jack’s case and acknowledge the limitations in care on the Island and implement better processes and procedures to ensure that complex medical situations can be managed with appropriate support and assistance from the larger/more experienced hospitals in the UK. Such arrangements will foster better medical care and a safer culture for Island families. Indeed, as the evidence before the inquest found, had such arrangements been in place and/or used in Jack’s case, he could be alive today and celebrating his fifth birthday.