Derriford Hospital criticised by coroner over baby's death
A TWO-month-old baby died at Derriford Hospital after "bad failings" among staff, an inquest heard.
Ethan Cross's brain was fatally starved of oxygen when a breathing tube which had probably become dislodged was replaced too slowly, the hearing was told.
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Ethan Cross
He died due to the injury a week later, on November 14, 2009.
His mother Shelley Cross, aged 29, of North Prospect, attended the inquest yesterday.
Andrew Cox, deputy coroner for Plymouth, recorded a verdict of death by misadventure.
He said: "In my view there were failings, bad failings even. There was not, however, a total and complete failure."
Describing the events that led to Ethan's tragic death, Mr Cox said "individually competent people failed collectively in this critical situation".
He noted a lack of experience and confidence in a new doctor expected to take charge of the emergency.
An in-depth investigation was carried out by the hospital following the incident. It lead to changes around training, reviewing new doctors, team working and management of ill babies.
Ethan was born on September 7, 2009. The birth took place at a specialist hospital in Bristol because some of his organs were growing outside his body.
He underwent a successful operation to correct the life-threatening condition when he was just a couple of days old.
The inquest heard Ethan had suffered a number of incidents where his blood oxygen and heartbeat fluctuated while in Bristol.
However, as he had been improving and his condition was considered no longer life-threatening, he was transferred to Derriford Hospital on November 6 on a ventilator.
Staff in the neonatal intensive care unit that night included an experienced staff nurse who was tasked with giving Ethan one-to-one care, and a ward sister who had worked on the unit for 10 years.
There was also two new doctors, a specialist registrar in charge of the ward and a senior house officer. Both had worked in the neonatal unit for about two months. There was also a consultant on call.
Dr Cox said the "critical event" happened at around 4am on November 7.
He said the "likely trigger" was his breathing tube becoming displaced from his windpipe into his oesophagus.
Mr Cox described staff's initial response as "appropriate", including Ethan being given oxygen and increased ventilation. He said that the consultant, who was telephoned at about 4.15am, was called at the right time and responded appropriately.
However, before the consultant arrived, the emergency needed "confident clear leadership", which the registrar was expected to provide and did not do so, the coroner said.
He said staff had relied too heavily on listening to Ethan's chest to check whether the tube was in place. An expert witnesses had described the method as "notoriously difficult".
Mr Cox said the registrar's actions were those of a doctor with "little experience" of the specialist skills required, and "lacking confidence" to lead in an emergency.
The tube was finally removed on the advice of the consultant, who was on his phone en route to the hospital. He arrived shortly afterwards and replaced it but by that time the damage was done.
Robert Antrobus, partner and head of clinical negligence at Foot Anstey, who represented the family during the inquest, said: "The family are grateful to the coroner for his thorough review of the events leading up to Ethan's death.
"Sadly the coroner, delivering a verdict of misadventure, has found evidence of substandard care which has played a significant part in baby Ethan's death.
"The family does however acknowledge that the Trust have undertaken a full investigation which highlighted problems with Ethan's care through its serious untoward incidents (SUI) procedure. Indeed, it is reassuring to note that the trust has identified steps to take, and improvements to be made, following Ethan's death. The family sincerely hope that the lessons learned in this tragic case result in other families not having to go through what they did."
Plymouth Hospitals NHS Trust yesterday released a statement detailing "robust" changes made following the death.
A spokesman said: "We offer our sincere sympathies to the parents and family of baby Ethan.
"This was a very sad case and we are extremely sorry that there were failings in the care given to Ethan.
"As the coroner noted during the inquest, we had undertaken a full investigation into what happened and, as a result, we have made a series of robust changes within our neonatal intensive care unit during the past year."
A spokesperson for Plymouth Hospitals NHS Trust, said: “We would like to offer our sincere sympathies to the parents and family of baby Ethan.
“This was a very sad case and we are extremely sorry that there were failings in the care given to Ethan.
“As the Coroner noted during the inquest, we had undertaken a full investigation into what happened and, as a result, we have made a series of robust changes within our Neonatal Intensive Care Unit during the past year.
“We have
Introduced carbon dioxide monitoring as a standard part of care for ventilated infants – these sensors detect exhaled waste gases which can give early warning of a displaced breathing tube.
Put in place measures to ensure that all staff undertake and update their Newborn Life Support training and accreditation.
Put in place multi-professional emergency scenario training using a new simulation mannequin within a dedicated resuscitation training area. This training starts at induction when any new member of medical staff joins the neonatal team. This helps to develop better emergency team working and leadership skills.
Introduced a tool, which in addition to the standard assessment of medical staff in training, allows us to better share information about their competencies and/or their support needs.
Developed better documentation which shows the presence of the senior medical and nursing leads at all ward rounds and handovers.
“We will, of course, consider the Coroner’s full findings and look to see whether any further changes are needed.”
11 Comments
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by crazypenguin
Wednesday, February 08 2012, 9:24PM
“Apprently this poor little mite died because a breathing tube came out and wasnt noticed fast enough, all I can say is this is the kind of thing that can happen when you cut the number of nursing staff/doctors/midwives while at the same time paitent numbers are increasing, of course staff arent going to be as attentive because they are simply spread to thinly among to many paitents.
The nhs is drastically underfunded I noticed even though I had a good experience with the staff, listening to them during the delivery they were having trouble tracking down certain equipment because they did not have enough to go round all the delivery rooms etc.
Rip to this poor child but all I can think is if we dont start pumping money into the nhs this type of event is bound to happen more frequently, by on large the staff have the skills needed they just dont have enough of them to give every paitent the care they deserve.
I say when hrmc actully get the taxes owed from big business`s (if they ever bother to) they cancel the cuts to the nhs and instead start pumping money into it, it is after all a resource used by all and benefiting all. But of course the government doesnt care, why would they? theyve never been a people party, the tories and there wealthy buddys all use private healthcare Id be willing to bet.”
by prophetofdoom
Wednesday, February 08 2012, 6:09PM
“Such a sad story. From personal experience I know the problem is too many managers and not enough front line staff, both medical and non-medical. Hopefully lessons wil be learnt so that this may never happen again.”
by superwoman123
Wednesday, February 08 2012, 5:27PM
“sending my condolences to ethans family
i,ve had all my children at derriford and all the staff bar 1 she,s was horrile to everyone
the rest were top excellent. the nurses /doctors and all saved my life at one point so please don,t tar all the staff by the same brush they do a fantastic job lots of hours work and do alot of hard work/training to do there job but sadly none of them are god i cannot praise derriford enough shame they don,t get payed enough !!”
by Thugpug
Wednesday, February 08 2012, 2:52PM
“Both my children were born in derriford in 2008 & 2010. The babies both had difficult starts. Some staff were fantastic, some, incompetent.
Sadly, a beautiful little boy has lost his life. This is such an emotive situation and is bound to bring strong feelings for commentators. Some positive, some negative. Lets not argue between ourselves. It is great for those that have had a positive experience with derriford. However, there are also those, (including myself) who had mixed treatment. Lets all be grateful for those of us who have healthy children and stand together as parents in support of those who have experienced what NO parent should ever have to experience. No parent should bury their child. Be thankful your kids are safe and well.”
by stevodevo
Wednesday, February 08 2012, 12:13PM
“crazypenguin - i'm glad you had a good experience at Derriford.
Our baby was also, like poor little Ethan Cross, born in 2009 and was in transitional care for a week. (We believe he contracted an infection during delivery.)
While some of the transitional care staff were lovely, caring and efficient, others, including doctors and pediatric specialists who became involved, treated us and our baby as though we were ignorant nuisances.
We were so relieved to get out that we didn't make a formal complaint, but at times I wish we had.
I'm pleased that Derriford has accepted its service wasn't good enough.”
by crazypenguin
Wednesday, February 08 2012, 11:36AM
“ryan1988 How would I know what im talking about? maybe because my last week or so has been spent up derriford watching my wife endure a hard labour and then visiting her and the baby for a week in hospital seeing the standard and level of care on a first hand basis, thats how I know what im talking about mate, the nursing staff actully saved my child when she first came into the world and needed oxygen to start her breathing propaly, they then looked after my wife and baby impeccably while on the ward, I just see the non stop crticism the staff at derriford get and its really not deserved, considering the declining resources and staffing levels as well they do a damm good job. I dont know anything about the case in question thats why I didnt comment on it however I just thought people should know of a very good experience at this hospital it isnt all `evil no nothing nhs nurses ` as some people seem to think.”
by pipmonster
Wednesday, February 08 2012, 9:01AM
“Makes it very sad as the Herald have now put a picture of the poor little mite instead of the front of the hospital as earlier.
My heart feel condolences to his family and their friends.”
by Potbelly1
Tuesday, February 07 2012, 11:40PM
“At the end of the day the Coroner had caused to investigate the death of Ethan ..He was one of three unexpected deaths of children at the hospital and one of 109 SUIs between January 2009 and October 2010 as revealed to the BBC after a freedom of information request... death by misadventure was recorded by the Coroner and the hospital has been criticised with 'failings in care' by the coroner..Remember the coroner gets to know all the facts! .....something went wrong with this baby's death! lets hope by this report this NEVER happens again BABY ETHAN had the RIGHT to live! and should of had the chance!”
by ryan1988
Tuesday, February 07 2012, 10:07PM
“id just like to say to crazypenguin how would you know unless you have been or have lost a child and comments like that should be kept to yourself, how on earth would you know what the family are going through as your case isnt even similar to what has happened here, a healthy baby has been let down by supposedly qualified and compitent staff, not a chance”
by crazypenguin
Tuesday, February 07 2012, 8:59PM
“Id defend this hospital and its staff, I dont know about the case in question but ive recently had a child who was slightly early and as a result a small baby, her mother also devloped high blood pressure and was in hospital as a result for 5 days in the transitional care ward(for babys that need a little monitoring but not quite enough to go into an intensive care ward)
The staff, midwives doctors and nurses who helped to deliver our baby and those on the ward were brilliant they looked after my wife and our baby very well and were very knowledgable and caring cannot fault them at all.
This is espcially good considering due to the latest round of nhs cuts they are working with a lot less beds(I understand upon reading derriford used to have 2 maternity wards they are now down to just 1 got instance) and a lot less staff to cope with a rising number of paitents.
These people do an awesome job, give them the funding they need and the service would be faultless....of course try telling the tories that.”