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Inquest at Southwark Coroner's Court prompts Prevention of Future Deaths Report

Poor communication at hospital criticised after baby's death

Posted on 26 March 2015

Specialist clinical negligence solicitor, Dr Mala Sidebottom, represented the family of a baby who tragically died at five days of age.

X was born at Queen Elizabeth Hospital, in Woolwich, on 24 March 2013.  Two hours after his birth he suffered a respiratory arrest and was resuscitated and subsequently transferred to St Thomas’ Hospital for therapeutic cooling.  He was found to have had extensive brain haemorrhage and hypoxic ischaemic encephalopathy and died on 29 March 2013.

Following a three day inquest at the end of February 2015, Dr Philip Barlow, sitting as Coroner at Southwark Coroner’s Court, found that there were breakdowns in communication between the healthcare professionals and with X’s parents, which contributed to the delay in recognising X’s deteriorating condition.

The Assistant Coroner recorded a narrative verdict and has written a report, seeking to prevent future deaths at the hospital.  In his report, Dr Barlow deals with the poor communication between the health professionals amongst themselves and with X’s parents. 

He also raises concerns about the practice of documenting observations on a piece of paper which was not retained within X’s medical records.  As the records were not immediately available when key observations were carried out by a midwife on X, she had written on a piece of paper.  These results were later transcribed into the medical records by another midwife but the piece of paper was not retained.

Dr Sidebottom in the medical negligence team at Leigh Day said:

“I am pleased for the family that the Assistant Coroner felt that matters were sufficiently serious to write a Report to Prevent Future Deaths to the Trust, although, sadly, any action taken as a result of the Inquest will not bring X back.”