Very serious error at maternity unit led to death of premature baby

A Coroner has found that ‘systemic failure to ensure sufficient availability of the correct equipment to deliver the TPN’ was one of the factors that led to the death of a baby who was born prematurely at 27 weeks at Queen Charlotte’s Hospital.

The parents of Baby C were represented by medical negligence solicitors Suzanne White and Emma Kendall at the inquest into the baby’s death.

After being born prematurely Baby C needed Total Parenteral Nutrition (‘TPN’), a feed that must be given to all babies born before 30 weeks gestation.  

The administration of the feed requires a volumetric pump. However, at the time Baby C was being cared for on the unit, there was a shortage of volumetric pumps as all fourteen were in use. This had been a problem for some time.

The nurses in charge of Baby C were concerned about the lack of pumps but proceeded to administer part of the nutritional solution known as ‘Vamin’ to Baby C using a syringe driver.

The use of syringe drivers to administer Vamin was in breach of the policy of the Neonatal Unit, as well as being a breach of the National Patient Safety Alert of 2010.

The nurse responsible for administering the feed through the syringe driver was unfamiliar with the way in which the equipment had been set up and sought reassurance from a colleague about what should be done.

When the feed was eventually administered to Baby C, the nurse in charge of his care failed to check that the clamps on the syringe were properly closed. As a result, Baby C received an overdose of TPN.  

The clamp had, in fact, remained open and the entire contents of the hanging Vamin bag (a 24 hour dose) were given to Baby C in around 30 minutes.

Baby C’s condition deteriorated and he subsequently a bleed on the brain. Baby C died in his parents’ arms on 21 August 2015.  

At the inquest into Baby C’s death, the Coroner concluded that Baby C died because of:
 

1.    Intraventricular haemorrhages
2.    Hyperglycaemic overdose of TPN feed
3.    Prematurity

The Coroner recorded a narrative conclusion which stated:

‘‘Baby C was born prematurely and required treatment including the administration of TPN. There was a failure to ensure correct administration of the TPN resulting in its over-infusion. In particular, there was a systemic failure to ensure sufficient availability of the correct equipment to deliver the TPN. The failings more than likely led to the eventual outcome.’

At the inquest a representative of the Trust gave evidence about the systemic failings, and in particular the shortage of volumetric pumps. The Coroner was advised that since this incident, the unit has used charitable funds to buy 25 pumps to ensure that such tragic events do not re-occur.

Suzanne White, medical negligence partner at Leigh Day said:

“This deeply shocking and tragic case. A vulnerable premature baby has died as a result of shortage of equipment at hospital that is known as a centre of excellence.

“Whilst we understand the Trust has now invested in the required pumps what was evident from the evidence at the inquest was that there was a complete breakdown of communication between the doctors and nurses. This must not be allowed to happen again.

Medical negligence solicitor at Leigh Day Emma Kendall, added:

“It is deeply concerning that this gross failure has occurred at one of our leading maternity units. We hope that the Coroner’s findings will act as a wake-up call to not only those involved in this case, but all practitioners responsible for the care of vulnerable, premature babies.”