BABY DIED IN HOSPITAL AS STAFF FAILED TO NOTICE DISLODGED TUBE
‘Missed opportunities’ contributed to tragedy
‘MISSED opportunities’ contributed to the death of a baby in hospital – just eight days after his twin brother died.
Grieving parents Daniel and Nicola Rushton-walley were already reeling from the loss of baby Kole when his brother, Masen, passed away at Manchester St Mary’s Hospital in May, 2016.
An NHS investigation into the fatal blunder has since identified a number of improvements – which have now been introduced – to ensure the mistake is not repeated.
An inquest yesterday heard how Masen died after an endotracheal tube – used to help him breathe – became dislodged. The problem was not spotted quickly enough, and the tot died.
Nicola, aged 30, from Birches Head, told the inquest: “I had not left his side from the day he was born. He was stable and I felt assured Masen was fine to leave and I went to Ronald Mcdonald House. That was at 10.30pm.
“I had a telephone call at 7.05am the next morning, telling me to come straight across. By the time I arrived, Masen had passed away.”
Kole and Masen were born prematurely at 28 weeks at the Royal Stoke University Hospital. Kole was extremely poorly and died just six hours later after suffering constant high blood pressure.
Four days after his birth, Masen was transferred to St Mary’s Hospital with a suspected bowel infection, underwent successful surgery a day later, and was in a stable condition when tragedy struck.
Nurse Jordan Washington was responsible for Masen’s care on the night he died. She had changed his nappy and, with the help of another nurse, repositioned him to prevent pressure sores. It is likely that the tube became dislodged when Masen was moved.
Nurse Washington said: “There was not a good trace on the monitor. I thought this was because of the procedure of repositioning. He looked fine on the ventilator.”
The inquest heard that when an alarm went off, nurses believed it was a problem with the monitor, rather than Masen himself.
They noticed Masen’s chest was not moving and manually ventilated him using a mask and pump – which was connected to the endotracheal tube – without realising it had become dislodged.
Expert consultant Dr Catherine Johnson was brought in by Manchester University NHS Foundation Trust to review the case.
She said: “By the time it was recognised that the tube had been dislodged, it was too far down the line for Masen to be able to recover from that.”
Asked by the coroner whether there was ‘a period when an opportunity was missed to save Masen’, Dr Johnson said: “Yes.”
She added: “Had it been done sooner, there was a chance resuscitation would have been successful.”
The inquest heard two forms of monitoring are normally placed on babies – and an ECG scanner would have provided an early warning – but only one monitor was in use.
Since Masen’s death, guidelines have been introduced to ensure two monitors are used.
A post-mortem examination gave the cause of death as ‘acute collapse in a premature baby caused by a dislodged endotracheal tube’.
Recording a narrative conclusion, assistant coroner Sally Hatfield told the inquest that a delay in recognition and missed opportunities contributed to Masen’s death.