University Hospitals of North Midlands NHS Trust

2. Ms B complains about the care and treatment provided to her newborn child, Baby B, from University Hospitals of North Midlands NHS Trust (the Trust). Ms B says the failings in care identified by the Trust during its review caused her baby’s condition to deteriorate and contributed to their death.

3. Ms B says there may have been additional treatment options available to her baby and they may not have died if the failings identified in the Trust’s review had not happened. Ms B says this has caused her a great deal of distress.

4. Ms B would like the Trust to acknowledge the impact the failings had, apologise and make a financial award to the family in line with the Ombudsman’s guidance on financial awards.

5. Baby B was born by breech delivery. They were premature, born at 32+5 weeks gestation. The Trust provided initial care before transferring them to the Paediatric intensive care unit (PICU) at a different Trust the next day. Baby B remained in intensive care but sadly died a few days later.

6. Following a postmortem examination the coroner said:

‘In my opinion, the reason for Baby B’s sudden, profound desaturation and death was pneumothorax (collapsed lung) from the accumulation of a large volume of air between the lungs and chest wall.

Pneumothorax is caused by the rupture of the lung’s small air sacs and is a recognised complication of lung disease of prematurity/respiratory distress syndrome. Baby B’s pre-existing lung damage was severe, rendering the tissue extremely fragile and susceptible to disruption.

The post-mortem examination identified a small bowel perforation, extensive liver damage and kidney injury. These almost certainly occurred because of severely impaired circulation and oxygen delivery to these organs (hypoxia-ischaemia), the precise cause of which remains undetermined. Potential contributing factors include infection and impaired placental function.’

7. The postmortem said the cause of Baby B’s death was:

1a: Large right-sided pneumothorax.

1b: Hyaline membrane disease (a lung disorder in premature babies which can cause breathing difficulties and respiratory failure).

1c: Moderate to late prematurity.

2: Submassive hepatic necrosis (a severe form of liver damage which can lead to acute liver failure), jejunal perforation (a tear in the small intestine which can lead to infection), acute renal tubular injury (kidney damage), pulmonary hypertension (high blood pressure in the lung arteries).

8. The Trust carried out a review using the Perinatal Mortality Review Tool (PMRT, a standard, national tool which reviews the care provided when a baby dies within the first 28 days of life) following the incident and found failings in the care it provided to Baby B. The Trust said although there were failings in the neonatal care, they didn’t have an impact on Baby B’s outcome.

9. Ms B disagrees and says the failings led to the hypoxia-ischaemia which caused the submassive hepatic necrosis, jejunal perforation, acute renal tubular injury and pulmonary hypertension identified in the postmortem. She says there may have been additional treatment options available for the pneumothorax, if it wasn’t for these additional problems.

13. Our adviser said the records indicate baby B had several risk factors for developing a pneumothorax. A significant factor along with their prematurity was that they had preterm prelabour rupture of membranes (PPROM) at 23 weeks. PPROM is a pregnancy complication where the amniotic sac surrounding the baby breaks before week 37 of pregnancy. It can increase the risk of infection and the chances of premature birth. It can also lead to lung hypoplasia (when the lungs don’t develop as usual) which increases the risk of developing severe lung disease and having pneumothoraces.

14. The GMC guidance states:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient

• promptly provide or arrange suitable advice, investigations or treatment where necessary

• refer a patient to another practitioner when this serves the patient’s needs.

In providing clinical care you must:

• provide effective treatments based on the best available evidence

• consult colleagues where appropriate.’

15. The NICE guidance says when providing oxygen treatment for babies born premature clinicians should measure oxygen saturation and, after initial stabilisation, aim for an oxygen saturation level (the level of oxygen in the blood) of 91% to 95%.

16. Baby B was born at 5.41pm and the records indicate they had a slow heart rate (less than 100 bpm), were not breathing and the Trust immediately commenced oxygen treatment. At 10 minutes Baby B’s oxygen saturation levels were recorded as 92% and their heart rate had increased to 191bpm. At this point the Trust started preparations to transfer Baby B to the PICU.

17. At 22 minutes the Trust intubated (inserted a tube into the airway to keep it open) and ventilated (controlled his breathing with a ventilator machine) Baby B to maintain their oxygen saturation level and the records indicate the Trust provided treatment with surfactant and antibiotics. The records indicate the Trust transferred Baby B to the PICU at 6.30pm the following day.

18. We found the initial care and the plan put in place by the Trust to escalate Baby B’s care was in line with the GMC and NICE guidance. As Baby B sadly died 13 days after they were born, the Trust carried out the PMRT and identified incidents of inadequate record keeping, malfunctioning equipment and delays in treatment.

19. The first failing identified in the PMRT was:

‘It was not possible to tell from our medical records whether Baby B was assessed appropriately on arrival on the neonatal unit, as no initial assessment of them was documented in the medical notes. Also, no early management plan was documented.’

20. We acknowledge that the Trust has accepted this failing. Our adviser said there is no evidence to indicate the lack of this specific documentation had an impact on Baby B’s care at that time. Although there is no initial assessment or early management plan in the records, they do contain nursing records of Baby B’s management following their birth, an observation chart of their admission to the neonatal unit and medical records of their ongoing care

21. We have not seen any evidence to indicate there was a lack of information available to the clinicians during this period. We have not seen any evidence to indicate any aspect of Baby B’s condition or the care they required was overlooked because of this failing. The records support the view that Baby B’s condition was stabilised on the delivery unit and they were transferred to the PICU without any delay.

22. The next failing identified in the PMRT was that the transport ventilator was not working in the delivery suite.

23. The discharge summary in the records says ‘ventilator on transport incubator not working - nurse to attend from PICU to help. Vent now working’. The records indicate Baby B’s breathing in the delivery unit was supported with the equipment on the resuscitaire machine (a specialised medical device used to support newborns who need help with breathing and warmth immediately after birth) before their transfer to the transport incubator, which our adviser said is usual practice.

24. In its response to this point the Trust said a neonatal nurse was asked to attend from the PICU to review the incubator and when they arrived the ventilator was found to be working again. The records indicate Baby B was transported safely with the correct breathing support to the neonatal unit.

25. Our adviser said there is no evidence in the records to indicate this had an impact on Baby B’s condition at this time or that it contributed to the hypoxia-ischaemia identified in the postmortem. We found Baby B’s oxygen was appropriately provided through the resuscitaire machine and we found no evidence to indicate this led to any delay or lack of care at this time.

26. The next failing identified in the PMRT was a delay in administering surfactant. The Trust acknowledged that surfactant was not provided until 1 hour after admission to the neonatal unit.

27. Surfactant is a naturally occurring substance made by the lungs. It reduces surface tension inside the alveoli (the tiny air sacs where oxygen is exchanged) and keeps them from collapsing between breaths. Without surfactant, alveoli can stick together making it hard for a baby to take in enough oxygen. Premature babies, especially those born before 32 weeks, often don’t have enough surfactant at birth. Surfactant replacement therapy is delivered through a breathing tube directly into the lungs and is often given shortly after birth or when signs of respiratory distress appear.

28. The records indicate the Trust prescribed surfactant at 6.30pm and gave the first dose at 7.30pm. We acknowledge this was delayed and Baby B should have been given surfactant after they were intubated either on the delivery unit or on admission to the neonatal unit.

29. Our adviser said there is no evidence the delay in providing the first dose of surfactant had an impact on Baby B’s condition or outcome. The records indicate that Baby B had significant lung disease when they were born, most likely due to their PPROM. The findings of the postmortem support this and it makes specific reference to the extent of the lung disease saying ‘lungs show significant hilum membrane disease alveolar damage.’

30. We found no evidence which would indicate giving surfactant earlier would have made a difference to Baby B’s lung disease or prevented their deterioration in the days that followed. After the initial delay the surfactant was provided and followed with further doses to assist Baby B with their symptoms.

31. The next failing identified in the PMRT was a delay in administering antibiotics. The Trust acknowledged the antibiotics were delayed for approximately 20 minutes.

32. The records indicate the Trust prescribed antibiotics at 6.30pm and provided them at 7.20 pm. Antibiotics are given to newborn babies who have respiratory distress and they are continued until sepsis (infection) has been ruled out. Antibiotics are usually stopped after 36 hours if blood tests show no evidence of raised infection markers and blood cultures are negative.

33. Our adviser said there is no evidence the delay in starting antibiotics had an impact on Baby B’s condition. Our adviser said antibiotics are given intravenously and the records indicate it was difficult placing the IV catheter which may have led to the delay. After the initial delay antibiotics were provided and continued throughout the admission at the Trust. The records indicate Baby B’s initial infection markers were normal whilst at the Trust and not raised.

34. We found no evidence to indicate starting antibiotic treatment sooner would have had any impact on the effectiveness of the treatment or prevented the deterioration Baby B experienced in the days that followed. We found no evidence to indicate this failing contributed to the hypoxia-ischaemia identified in the postmortem or that it led to a missed opportunity to provide further treatment.

35. The next failing identified in the PMRT was a delay in administering a bicarbonate solution to correct metabolic acidosis (a condition where excess acid accumulates in the body).

36. The records indicate the Trust provided sodium bicarbonate at 2.20pm the day after their birth to help Baby B’ poor kidney function. Our adviser said poor kidney function is a common problem for preterm babies to develop shortly after birth and sodium bicarbonate is an appropriate treatment to help with this.

37. Our adviser said there is no evidence we can point to which would allow us to link the delay in providing sodium bicarbonate for metabolic acidosis to the deterioration Baby B suffered in the days that followed, which was linked to the problems with their lungs. We found no evidence to indicate the length of time that passed before the Trust provided sodium bicarbonate had a detrimental impact on Baby B’s condition or his chances of survival.

38. The next failing identified in the PMRT was a delay in obtaining a lateral X-ray after the abdominal X-ray.

39. Our adviser said the X-rays performed by the Trust were appropriate but agreed there was a delay in performing the lateral (side view) X-ray. Our adviser said the delay would not have changed the Trust’s management of Baby B’s care as once the initial indications of a possible pneumoperitoneum (air in the abdomen) was identified in the original abdominal X-ray the Trust discussed the finding and Baby B’s ongoing care with the paediatric surgeons at a different Trust without delay.

40. We carefully considered Ms B’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing it was for Ms B to learn of the failings identified in her baby’s care and we acknowledge her view that these failings contributed to her baby’s death.

41. We found no evidence to indicate the failings identified in the PMRT had an impact on Baby B’s condition. We found no evidence which would lead us to conclude the failings caused the hypoxia-ischaemia identified in the postmortem or that they contributed to the deterioration Baby B suffered in the days that followed their birth. We found no evidence which would indicate there was more the Trust could have done to prevent the deterioration Baby B suffered in the days that followed.

1. We have decided to not uphold Ms B’s complaint. We acknowledge how upsetting this incident was and that it continues to cause her considerable distress. We found the failings in care identified by the Trust did not have an impact on her baby’s outcome.