Finding of neglect following the death of newborn at acute district general hospital
Bronia Hartley represented the family at a four-day inquest in the Nottingham and Nottinghamshire Coroner’s Court concerning the death of a 15-day-old baby following an unexpected collapse at home, the underlying cause of which could not be ascertained.
HM Assistant Coroner Dr Elizabeth Didcock found significant failings in respect of the care provided by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust following the baby’s presentation at Bassetlaw Hospital in a critically unwell condition. The Coroner found that delays in intubation and referral to the specialist paediatric critical care transport service contributed to the baby’s death. A narrative conclusion recorded that the death was contributed to by neglect.
The Coroner also identified failings in team coordination and leadership during the resuscitation effort, specifically the absence of a clearly identified clinical leader, failures in communication between senior clinicians, and a resuscitation team that became overly focused on individual tasks, resulting in its collective failure to appreciate the acuity of the baby’s condition. Additional concerns were identified regarding equipment availability, warming measures, drug administration and the recording of observations.
The Coroner issued a Prevention of Future Deaths (Regulation 28) report concerning the ability of the paediatric resuscitation team at the hospital to manage critically ill infants and communication and engagement with specialist regional paediatric critical care services. The report will be copied to the Yorkshire and Humber Paediatric Critical Care Operational Delivery Network, the Care Quality Commission and NHS Nottingham and Nottinghamshire Integrated Care Board.
This was a particularly difficult and sensitive case involving the death of a much-loved newborn child which demonstrates the vital role of the inquest process in identifying systemic failings, obtaining answers for bereaved families and promoting improvements in patient safety.
Bronia Hartley was instructed by Sadie-Jo Simpson of Ison Harrison Solicitors.
Bronia Hartley is part of the Inquests Team at Parklane Plowden. Bronia’s profile can be accessed here.
