Key Points
- A Fatal Accident Inquiry (FAI) has concluded that the 2019 death of three-year-old Archie Donald at Glasgow’s Royal Hospital for Children might have been avoided.
- Sheriff Millar’s determination identified specific defects in systems of working, including the failure to act upon abnormal blood test results.
- The inquiry highlighted a lack of post-clinic multidisciplinary review and a failure to follow established clinical guidance and the child’s specific care plan.
- Archie Donald had been receiving long-term care at the hospital since he was six weeks old, with his mother previously expressing concerns regarding systemic issues within the facility.
- The Procurator Fiscal led the evidence during the inquiry, ensuring a comprehensive examination of the circumstances surrounding the toddler’s death.
Glasgow (Glasgow Express) May 5, 2026 — The tragic death of three-year-old Archie Donald in 2019 at the Royal Hospital for Children in Glasgow could have been prevented had medical staff identified and acted upon an abnormal blood test result in a timely manner, according to a recently published Fatal Accident Inquiry (FAI) determination. The inquiry, which scrutinized the clinical care provided to the toddler, highlighted systemic failures that contributed to his untimely passing. Sheriff Millar, presiding over the inquiry at Glasgow Sheriff Court, concluded that there were clear defects in the working systems at the hospital, which ultimately led to the missed opportunity to address the infection that claimed the boy’s life.
As reported by the BBC, Archie Donald’s mother, who had been caring for him since he was six weeks old, testified that she felt an intuitive sense that something was wrong with her son. During the inquiry, she asserted that it was “clear” to her and her family that systemic issues within the hospital led to failures in the care provided to Archie. She stated to the FAI,
“Had the infection markers in his blood tests been addressed sooner, had necessary tests been conducted earlier, or if someone had recognized that Archie was indeed suffering from an infection sooner, there is a possibility my son would still be alive today”.
According to evidence presented during the inquiry, Archie visited the hospital the day before his death for a routine check-up, appearing
“lethargic, breathless, and with a decreased appetite”.
As noted by the BBC, a consultant, Dr. Maxwell, detected a heart murmur that had not been previously documented and subsequently ordered blood tests and an echocardiogram to investigate the possibility of bacterial endocarditis. Despite these steps, the inquiry found that the abnormal blood test results were not identified or acted upon with the necessary urgency.
In the early hours of November 20, 2019, Archie was found to be restless with a heart rate fluctuating between 160 and 178 beats per minute.
His mother activated the emergency buzzer at 3:25 AM due to the toddler vomiting and again 11 minutes later when he stopped breathing. Despite the efforts of the medical team to revive him, Archie was declared deceased at 4:36 AM. A post-mortem examination later confirmed the cause of death as subacute bacterial endocarditis.
Procurator Fiscal Andy Shanks, representing the Crown Office and Procurator Fiscal Service, addressed the findings following the publication of the determination. As reported by STV News, Mr. Shanks stated:
“The sheriff’s determination is detailed and notes a reasonable precaution that could have been taken to avoid Archie Donald’s death.”
He further emphasized that the FAI followed a “thorough and comprehensive investigation” by the Procurator Fiscal to ensure that the full facts and circumstances were presented in evidence.
What background led to the Fatal Accident Inquiry?
The inquiry into Archie Donald’s death was ordered as a discretionary Fatal Accident Inquiry due to the significant public concern surrounding the circumstances of his passing. The process involved an extensive examination of the hospital’s clinical practices, including staffing levels and the built environment of the Royal Hospital for Children.
Throughout the proceedings, evidence was gathered from paediatric consultants from NHS Greater Glasgow and Clyde, as well as a microbiologist, to assess whether the hospital’s environment or internal procedures contributed to the clinical failure.
The inquiry aimed to provide clarity for the family and to ensure that lessons were learned regarding record sharing, delay in admittance, and the identification of infections.
How will this development affect the healthcare system and patient safety?
The determination of this inquiry is expected to have a significant impact on clinical governance within the NHS Greater Glasgow and Clyde health board. By highlighting “defects in systems of working,” the findings serve as a critical catalyst for the review of communication protocols, specifically concerning the flagging of abnormal blood test results.
For parents and families relying on the hospital, this development underscores the necessity for more rigorous multidisciplinary reviews after clinics, ensuring that no patient data—particularly critical lab markers—is overlooked. It is anticipated that this scrutiny will compel the hospital to adopt stricter adherence to existing clinical guidance, potentially leading to more transparent monitoring of patient care plans and a more proactive approach to emergency response protocols to prevent similar tragedies in the future.
