A 'cheeky and happy' four-year-old boy died from a rare underlying heart condition within three hours of a GP sending him home, an inquest heard.
George Thomas Spencer, who had a history of contracting the viral infection croup, died on March 19 last year after staff at St James' CE Primary School in Clitheroe, Lancashire, noted his breathing was 'raspy'.
When his mother Danielle collected George from after-school club she noticed he was having difficulty breathing, so his father Terry took him to the GP.
The four-year-old boy was seen by Dr Jill Osgood at Clitheroe Health Centre on March 19.
At an inquest at Accrington Town Hall yesterday, Dr Osgood said she had experience of patients with croup which can be 'variable in its presentation'.
However, after assessing George, Dr Osgood said she found his heart rate, temperature and oxygen saturation were all 'within the normal parameters'.
Four-year-old George Spencer (pictured, left, with twin brother Arthur, right) died from rare underlying heart condition within three hours of a GP sending him home, an inquest heard
Dr Osgood said: 'He was very chatty and joking, speaking in full sentences, there was no hoarse voice but I did hear noisy breathing.'
George, who has an identical twin brother called Arthur, was taken back home but later that evening his parents noted a deterioration in his condition.
At around 7:15pm they noted his lips were blue and called an ambulance.
Their neighbour, a qualified first responder who had trained paramedics in using defibrillators, got a nearby machine which issued a shock to George's heart.
Paramedics then arrived at their home and carried out resuscitation attempts for some time before arriving at Royal Blackburn Teaching Hospital at around 8.30pm.
Paediatric consultant Dr Peter Fitzmaurice said he was called at 7:30pm ahead of George being brought in.
Dr Fitzmaurice said: 'The paramedics didn't arrive for about an hour so everything was getting a bit: "What's happened here?" because normally they just get them to hospital.
'Then it came through that they were having to resuscitate him at home which was why it was taking so long.
An inquest into George's death was held at Accrington Town Hall (pictured above) where a coroner recorded a narrative verdict after hearing George died from myocarditis in hospital
'George, who was born in Burnley in 2016, arrived at about 8.30pm but after continued cardiac compressions there had been no output. Resuscitation was very unlikely to have been successful.
'George was brought in, we did a quick assessment and I went to speak to parents to say there was no signs of life.'
A post-mortem examination revealed the cause of death was myocarditis - a 'notoriously difficult disease to diagnose', Dr Fitzmaurice said, which can develop after a viral infection and causes inflammation of the heart muscle.
The inquest heard that, even if George had been sent to hospital from the GP surgery, he would likely not have been given an electrocardiogram (ECG) which would have detected the myocarditis.
Dr Fitzmaurice said: 'From what mum and dad told me about George that day he was running round, he wasn't showing any signs of the heart failing in the build-up or two weeks before so there were no signs that George's heart was compromised.
'If you come into hospital it would still have been difficult to diagnose especially if there was croup beside it.
'We would have managed the croup because that was staring you in the face and we would have brought the tachycardia [fast heart rate] down.
'With croup you're not supposed to upset the child too much. It's one of the hardest things to diagnose in paediatrics. So it would depend on the level of tachycardia and at 130 we wouldn't be doing an ECG on a child.'
What is myocarditis?
Pictured: Normal heart muscle versus damaged heart muscle due to inflammation
Myocarditis is heart inflammation caused by a viral infection.
It is defined as inflammation of the myocardium - the heart muscle - and most people recover without any complications.
In severe cases, the inflammation can weaken the heart, cause an abnormal heartbeat, or even lead to death.
Symptoms typically include chest pain, shortness of breath, palpitations or an abnormal heart rhythm.
It is typically diagnosed using tests such as an electrocardiogram, a chest x-ray or blood tests to check for infection.
Patients can treat the condition with medication aimed at regulating heartbeat and improving heart function. Some rare cases have required patients to have a device implanted in their heart to regulate heartbeat.
The inquest heard that myocarditis can be caused by an infection and George had been 'susceptible to croup'.
Dr Fitzmaurice said: 'George's heart had some inflammation on it from an infection at some stage which meant that it was susceptible to not functioning properly and that can present in different ways, and can stop suddenly by itself or it could have stopped if something had acted as a trigger.
'The heart rhythm was abnormal before it stopped and that's unusual in children. Where does the croup come into it and was it an attributable factor? It's not easy to say what would have happened with the croup with the heart being in the condition it was in.'
Area coroner Richard Taylor asked Dr Fitzmaurice if the croup had contributed to George's death.
The consultant said it was 'impossible to say with certainty' but added: 'I think that the croup did contribute to the irregular heartbeat but I can't say that 100 per cent. But the myocarditis could have proved fatal without the croup.'
George's parents, who attended the inquest, asked Dr Fitzmaurice if steroids prescribed by the GP would have prevented his death.
Dr Fitzmaurice said: 'It may have resolved the croup, which may have taken the stress off the heart, but the myocarditis could have progressed and three weeks later he could have been in hospital.'
Ultimately, Dr Fitzmaurice agreed that the croup 'could have been irrelevant' and that the myocarditis could have proved fatal on its own.
Dr Fitzmaurice said: 'He could have had a cardiac arrest that night without the croup.'
Pathologist Dr Jo McPartland from Alder Hey Children's Hospital, who confirmed the medical cause of George's death was myocarditis, said his heart was 'significantly enlarged'.
Dr McPartland said: 'It was around the size of a heart expected for a nine-year-old child and the ventricles were larger than normal.
'Under the microscope there were areas of inflammation. There were also areas where the heart muscle cells had died. Even allowing for George's bigger than average size his heart was around 50g heavier than it should have been.
'It's a rare condition but I have seen a few cases of sudden, unexpected death in children from myocarditis. One child was admitted to hospital, thought to have pneumonia but then died, and another died in their sleep. We often don't know it's there until we do a post-mortem and examine the heart tissue.'
George also had inflammation in his voice box, although Dr McPartland 'didn't think there was a critical narrowing of the airways'.
Despite this, she said the croup was a contributory factor in George's death as it can cause an irregular heart rhythm which can result in cardiac arrest, although she did also find three other viruses present in his system which could have caused the myocarditis.
Recording a narrative conclusion, Mr Taylor said: 'George Thomas Spencer died on March 19, 2021, from an inflammation of his heart to which more likely than not a contributory factor was an undiagnosed viral infection.'
After George's death his family and friends raised more than £8,400 to install defibrillators around Clitheroe as well as a memorial bench at the nearby beauty spot of Edisford Bridge where the family enjoyed spending time.