Baby 15
The court initially heard that the boy, a triplet, had suffered blunt trauma to the abdomen, causing purpling of the skin and bleeding on the liver. Air was allegedly injected into the nasogastric tube causing the intestines to swell. Later, the accusation was changed to deliberate injection of air into the boy’s bloodstream.
The expert panel said the boy had died from a subcapsular liver haematoma, or bleeding beneath the outer layer of the liver, caused by traumatic delivery. This resulted in haemorrhage into the surrounding abdomen and profound shock. This was not recognised before the child died.
In summarising their findings, the panel flagged more than a dozen problems that were likely to have contributed to the babies’ deaths. These ranged from failures in diagnosing disease, poor skills in basic medical procedures such as inserting chest tubes, poor management of common neonatal conditions like low blood sugar and a disregard for warnings about infections.
LANGDALE: [Child O]. At paragraph 23, you tell us you were working nights. Tell us of your involvement with [Child O] and when you learned of [Child O]'s death and how you felt about that?
MAYBERRY: So for [Child O] I was on the night of 22 June 2016 and I was working as a middle grade doctor, so on the Registrar rota. "At some point in the night, I don't remember the exact time, Sophie Ellis, who was the nurse looking after [Child O], requested a review of [Child O]'s abdomen because it was mildly distended. Although she was not worried about him, she felt he looked slightly uncomfortable. When examining [Child O] I could feel that his abdomen was soft although it was slightly distended, he wasn't uncomfortable. This would be a common finding in a child on high flow nasal cannula oxygen and I wasn't particularly concerned about him.
LANGDALE: You say at paragraph 49: "There was a lot of discussion amongst the doctors at handover following [Child O]'s death as there were still two siblings who were alive and we wanted to ensure that we considered how best to manage them. This was a medically unexplained event but there were no concerns about mismanagement or suspicions that someone was to blame as far as I was aware." How can you say there were no concerns about mismanagement or suspicions when no one knew how the death had arisen? Until that has been investigated, you can't assert there were no concerns, can you?
DrU: I think what I'm meaning in that paragraph is that there was no event attributable to that -- that decline. It wasn't that a tube had been displaced or pushed too far, it wasn't that an incorrect medication had been administered as far as recorded on the prescription chart or recorded in the notes. I'm not sure that any of us would have considered a deliberate act.
Even the other doctors were reliant on previous doctors notes to make their next medical decisions- I have questions about the validity of all the note keeping and its impact- aka the snowball effect