- Summer Hawcroft died from a hypoxic brain injury which appeared to develop after breathing tube attached to the ventilator became dislodged
- Doctor who treated her had no specific training in incubation procedures
- Post-mortem showed brain injury but said there could be a number of possible causes?
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A newborn baby died from a severe brain injury after her breathing tube was dislodged in a hospital neo-natal unit, an inquest heard.
There was a significant delay before staff realised the tube was displaced by which time tiny Summer Hawcroft, who only weighed two pounds and two ounces at birth, had been starved of oxygen.
She suffered respiratory problems and was transferred from Barnsley District Hospital to a specialist unit in Sheffield but later died when she was just 49 days old.
Tiny Summer Hawcroft died from a severe brain injury after she was born prematurely and needed the help of a ventilator
Pathologist Dr Mudher Al-Adnani told the hearing that Summer died from a hypoxic brain injury which appeared to have developed after the endotracheal tube attached to the ventilator becoming dislodged.
The Sheffield inquest heard Summer was born prematurely by caesarean section after 27 weeks gestation on April 23 last year and was the seventh child of builder Stephen Hawcroft, 37, and his wife Michaela, 26, of Kendray, Barnsley.
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Paediatric registrar Dr Ash Kale said the infant needed resuscitation and was given inflation breaths before being incubated and then placed on a ventilator.
He failed three times to insert a 2.5 millimetre tube down Summer?s trachea to help with her breathing and had to use a smaller 2mm tube.
An independent expert who investigated the case said he found it 'puzzling' why staff were unable to use the larger tube which opens up the airways more.
Summer Hawcroft had difficulties because of the immaturity of her lungs and kidneys
Summer Hawcroft's parents were at the inquest to hear about the death of their baby girl
Dr Kale said as the baby was put on the ventilator he got a 'crash call' to help with another sick baby in the unit but claimed it did not affect his management of Summer.
Despite her arterial blood-gas levels dipping overnight he saw an improvement and had no concern over the baby?s neurological condition.
'She had difficulties because of the immaturity of the lungs and kidneys but was making progress and going in the right direction,' he said.
The doctor told Laurinda Bower, who represented Summer?s parents , that he had no specific training in incubation procedures but the standard respiratory rate had been set for Summer.
That had to be reduced when the baby began over-ventilating.
He conceded that incorrect settings on ventilators were a common cause of complications with babies and over-ventilation or under-ventilation could lead to brain damage.
The doctor also defended only checking the baby?s blood-gas levels every three or four hours and said more frequent checks could have adverse effects such as causing anaemia.
Dr Kale said he did not believe Summer merited a transfer to more specialist unit by April 25 and replacing her breathing tube would have subjected the baby to unnecessary trauma and 'caused more harm than good.'
But a week later the baby?s condition had deteriorated and and in the early hours of May 4 the breathing tube became displaced and Summer was starved of oxygen.
Dr Al-Adnani said his post-mortem after Summer died in her mother?s arms on June 11 showed a long-standing hypoxic brain injury but there were a number of possible causes.
He said it could be not enough blood to get oxygen to the brain, low blood pressure or anaemia, something affecting the blood vessels leading to the brain or 'it could be a combination of several factors rather than single event.'
Summer was transferred from Barnsley District General Hospital (pictured) to a specialist unit
The pathologist said the aftermath of the brain damage was 'quite extensive and widespread' and it was consistent with the events of May 4.
After the bab7 deteriorated she suffered a cardiac arrest and required resuscitation and apparently afterwards suffered brain damage although no specific cause could be identified.
Dr Al-Adnani added that the brain injury was so severe it was 'unrecoverable.' If it had happened before May 4 it should have been picked up by two cranal ultrasound scans which were carried out in the previous week.
Summer?s parents had difficulty identifying her when they travelled to the Jessop Wing of Sheffield?s Royal Hallmashire Hospital where she was taken. She showed no signs of improvement and the Hawcrofts had to agree to palliative care until she died.
The hearing continues.
Read more:?http://www.dailymail.co.uk/news/article-2203121/Newborn-baby-died-severe-brain-injury-breathing-tube-dislodged-recovered-hospital.html#ixzz26ajn63Eu
Source: http://noahsarkconsulting.blogspot.com/2012/09/newborn-baby-died-from-severe-brain.html
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