A “beautiful” baby has died after glaring failures by hospital staff caused him to run out of oxygen for about 50 minutes, a coroner has ruled.
Finnley James Adam Morris’s parents have spoken of “the hell” they have been through since their son’s death at Blackpool Victoria Hospital, saying the actions of medical staff were “unforgivable”.
Finnley was delivered by forceps after her first-time mum Emma Morris was induced after reporting pelvic pain and a change in her baby’s movements, LancsLive reported.
After Finnley was born at 12:22 a.m. on October 1 last year, a number of failures, including missing equipment and a doctor unable to secure his airway, caused Finnley to run out of oxygen for around 50 minutes.
As a result, his brain suffered insurmountable damage from the lack of blood and oxygen supply, and Finnley died on October 5 after being transferred to Royal Preston Hospital.
An inquest at Blackpool Town Hall this week, attended by Finnley’s father Adam, ended on Friday with Coroner Alan Wilson’s ruling that without the missed opportunities to treat Finnley he would have survived.
The four-day investigation found that several minutes were wasted intubating Finnley because pediatric consultant Sunitha Peiris forgot to bring her reading glasses. While the registrar, Dr Suriya Dhulipala, had failed to intubate Finnley until he was joined by the consultant.
Dr Peiris arrived at the hospital 30 minutes after Finnley gave birth and she immediately asked why he hadn’t already been intubated. It wasn’t until 49 minutes after his limp and pale birth that he was finally given oxygen. A second attempt at intubation was successful.
The investigation also learned that there was a lack of leadership in the theater throughout the period after Finnley’s birth. A number of hospital staff, including nurses, midwives and doctors involved in Finnley’s care during her tragically short life, have testified and confirmed that no one has taken control of the situation.
After hearing testimony from a pediatric pathologist and two obstetricians, the coroner concluded that Finnley suffered a period of asphyxiation of about five minutes before being born due to a compression of the cord.
Recording a narrative conclusion, the coroner said: “There was a serious failure before 12:47 am when the situation became impossible to survive. The registrar was waiting for the consultant and there was an airway management failure. The intubation was not attempted and did not really take place until later, when the consultant arrived.
“When the consultant arrived, she appreciated the need for the intubation. So yes, that amounted to a blatant failure in the role of the registrar. Another glaring failure was that there was no leadership until the consultant arrived. I congratulate Nurse Hayley Knighton who has been the most impressive of the Trusted Witnesses.
“If anyone was trying to show leadership, it was her. She raised the issue of the pressure on the resuscitator and also indicated that maybe it was time to secure the airways and that she likely found herself in an awkward position to raise issues which she believes , had to be raised in the absence of leadership.
The coroner then asked if the doctors’ glaring failures had any impact on Finnley’s chances of survival.
“Obviously, the evidence confirms that this is the case,” he said.
“Every missed opportunity to provide care could have saved his life. After 0h47 [the point at which Finnley’s brain was irreparably damaged] there were other problems. I thought some of the witnesses could have been more open in their testimony to help this investigation. “
Although the coroner did not publish any report on the prevention of future deaths, he concluded that the negligence Finnley suffered, in not providing him with basic medical care, had contributed to his death.
“He died of a catastrophic brain injury, his death having been caused by neglect,” he added.
After the investigation, Father Adam Morris issued a statement in which he described the failings of hospital staff as “an unforgivable catalog of mistakes.”
“The past 12 months have been hell for me and my wife,” he said.
“Our son Finnley never had a chance to survive, due to an unforgivable catalog of mistakes that should never have happened. The fact that Blackpool Victoria Hospital admitted the causation of his death by failing not following due process and in breach of duty is a little leniency in what has been an incredibly difficult year.
“The level of neglect that Finnley suffered will never be forgiven and they will always be held responsible for the needless loss of our first child. You are putting your trust and your life in the hands of doctors who are said to be highly trained in their field. You expect them to be fully up to date with training and remember the fundamentals of life support and airway management.
“You certainly don’t expect them to put your newborn baby at risk of death by not providing enough oxygen for more than 50 minutes, by not providing care due to the loss of staff on the job. way to the theater, missing equipment that could not be located but was there from the start and failed to provide effective leadership during resuscitation. These failures ultimately cost our son his life.
“There were other mistakes, including when Dr Sunitha Peiris arrived and forgot her glasses, which prevented her from intubating Finnley immediately. Due to our experience we now have no confidence in our treatment at Blackpool Victoria Hospital.
“The effect of our loss will be felt forever throughout our lives. Instead of celebrating birthdays and milestones with our son, we are forced to do it at his grave. A way that no parent should have to. Finnley was a beautiful baby, of which my wife and I will always be proud.
“Despite the suffering he suffered, he continued to fight until the end. We have sworn to our little man that we will fight for his justice and can be proud of having done so, after the case is concluded. However, our fight will continue to ensure that those responsible will never again have the opportunity to cause such devastation. “
Victoria Beel, Senior Counsel at Slater & Gordon, who has represented Mr and Mrs Morris throughout the proceedings, said: “It is of great concern that errors can occur during such a fundamental requirement to secure the tracks. respiratory tract of a newborn. Finnley was needlessly without adequate oxygen for 50 minutes, which was impossible to survive.
“Despite an ongoing conversation at the cabinet level about the need to improve our maternity record, we still see the insane and preventable loss of babies at a devastating rate.
“I have been touched by the dignified manner in which Mr. and Mrs. Morris fought for justice on behalf of their son Finnley. I hope today’s coroner’s conclusion concluding that Finnley’s death was caused by neglect, will help raise standards in neonatal resuscitation.
Dr Jim Gardner, Medical Director of the Blackpool Teaching Hospitals NHS Foundation Trust, said: “I would like to apologize to the family on behalf of all of the members of the trust. We recognize that this was a devastating and life-changing event and hearing the impact statement read in court by the baby’s father, it’s hard to imagine the pain they felt in losing their child.
“While we fully accept and lament the mistakes that were made in caring for baby Finnley, we also fully recognize that this will not change the outcome and that it is something the family will live with for the rest of her life. For that, I am very sorry.
“Of course, we accept and support the coroner’s conclusions. I want to reassure that over the past 12 months we have studied it extensively and that the Trust has a solid plan in place to ensure that lessons are recognized and understood, improvements identified and new methods of work implemented throughout the organization. It won’t bring Finnley back to her loving family, but it will prevent future deaths from happening that way. “