Source · Prevention of Future Deaths

Toby Barwick

Ref: 2023-0030Deceased Date: 27 Jan 2023 Coroner: Graeme Irvine Area: East London Responses identified: 0 / 2 View PDF

Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, and the hospital failed to demonstrate that the underlying omission was corrected.

Date 27 Jan 2023
56-day deadline 24 Mar 2023
Responses identified 0 of 2
Child Death (from 2015)

Coroner's concerns

AI summary
Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, and the hospital failed to demonstrate that the underlying omission was corrected.
View full coroner's concerns
1. The inquest heard that infants of low birth weight have a higher chance of dying in circumstances of Sudden Infant Death Syndrome ("SIDS"). Upon discharge from a maternity unit mother should receive advice and documentation upon a number of issues including (but not limited to) SIDS and recommended safe practices to reduce risk. Mr & Mrs Barwick did not receive this material at UCLH. UCLH could not provide clear evidence that the factors that led to this omission had been successfully remedied.

Report sections

Investigation and inquest
On 17th February 202 1 this Court commenced an investigation into the death of Toby Wilbur Barwick age 2 months (date of birth 24/11/2020). The investigation concluded at the end of the inquest held between the 23rd and 26th January :2023 . I arrived at a short form conclusion of open conclusion . The medical cause of death was determined following a post-mortem examination; 1 a Unascertained
Circumstances of the death
Toby Barwick was born on 24th November 2020 at University College Hospital in London at 37 weeks gestation with a low birth weight of 2.1 kgs. On 12th February 2021 Toby's mother walked to her sister's home carrying her son at her chest in a fabric baby carrier device. On arrival at approximately 13.00hrs, Toby was sleeping. Mrs Barwick allowed Toby to nap in the carrier whilst she spoke to her sister, sitting on a sofa. Just before 14.15 Mrs Barwick found that her son was unresponsive, she shouted for help and removed him from the baby carrier. Emergency services were called and CPR was commenced. The ambulance service arrived and took over conduct of resuscitation , Toby was taken by ambulance to the local hospital. At hospital resuscitation continued until, at 15.43 doctors determined that continued action would be futile and Toby's death was declared.

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Report details

Reference
2023-0030Deceased
Date of report
27 January 2023
Coroner
Graeme Irvine
Coroner area
East London

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Mar 2023.

Sent to

Department of Health & Social Care
University College London Hospitals NHS Foundation Trust

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