Death of three-day-old baby sees hospital criticised

Weston Hospital.

Weston Hospital. - Credit: Archant

FAILINGS at Weston General Hospital contributed to the death of a three-day-old baby whose life ‘could have been prolonged’, a coroner has ruled.

Chloe Flavell died from a heart defect on April 3, and the hospital’s executive medical director has this week apologised for ‘failures’ which meant she received substandard care.

Parents Charlotte Edwards and her partner Marc Flavell took Chloe to the hospital after she had vomited overnight at their home in Weston, amid concerns she was not eating and had turned a little blue.

However, the family waited in A&E for more than an hour to be seen - triage nurse Nelson Paul later said receptionists had not told him there was a baby in A&E - and it took staff another 40 minutes to take Chloe’s temperature as a suitable thermometer could not be found.

She was also unable to be transferred to a ward because the hospital had no beds available in any department – a so-called ‘black escalation day’.


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Mr Paul told Flax Bourton Coroners Court he had never treated a child so young before and struggled to take accurate records of her temperature because the machinery was not suitable.

Mr Paul said: “When I saw Chloe she was breathing fine. She wasn’t struggling.

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“Both the heart rate seemed normal and her skin was a normal pink colour. I didn’t feel she was cold either.”

When a digital thermometer was tracked down – almost two hours after Chloe was taken into A&E - she had a temperature of just 33.4 degrees despite being wrapped in blankets.

Dr Christopher Knight, from Taunton’s Musgrove Park Hospital, criticised Weston Area Health NHS Trust (WAHT) over the delays Chloe faced, although Dr Irfan Naqash, who treated her, said they did not contribute to her death.

Chloe was successfully resuscitated once, but died later that day. A post-mortem revealed Chloe’s heart had a damaged left ventricle and she died of congenital heart disease.

Avon coroner Maria Voisin said she believes more could have been done.

She said: “It’s clear from the pathologist that (Chloe) died of natural causes, but I don’t think it would summarise the findings I have.

“I consider the failings I have found to have contributed to her death. On the balance of probabilities, her life could have been prolonged.”

WAHT’s executive medical director Nick Gallegos offered an apology to Chloe’s family for the ‘shortcomings’ in her care, and said a raft of improvements have since been made to A&E services, including the creation of a special paediatric resuscitation area.

He said: “This is an exceptionally sad case. We would like to offer our sincere apologies to the family for the failures in Chloe’s care and our thoughts are with them at this extremely difficult time.

“After Chloe’s death we launched our own extensive internal investigation. This detailed review revealed serious shortcomings in the standard of Chloe’s care in the A&E department.

“As a direct result of the trust’s own investigation, substantial changes to the way in which emergency paediatric patients are managed in our own A&E were introduced as a matter of urgency. This has dramatically improved the emergency care of babies at Weston.

“Paediatric admission and referral routes into the hospital have been fundamentally redesigned. We have more dedicated paediatric nurses on every A&E shift, better and quicker internal processes and new arrangements on transfers with neighbouring hospitals.

“The changes we have now introduced means that regardless of the status of A&E, and however busy the department is, the standards of care will not be compromised.”

In a statement issued through solicitors, Chloe’s parents said: “As a family we remain devastated by our daughter’s death, but we’re grateful for the support and kind wishes we’ve received in getting to the verdict.

“The full and frank investigation by Weston Area Health Trust has resulted in significant changes to their processes.

“Whilst it’s not our responsibility to attribute blame, we do believe that lessons have been learnt, and our hope is that if anything positive can come out of this, it’s that these changes will prevent other parents from going through what we have.”

n Full details of the improvements to Weston General Hospital following the WAHT investigation can be viewed at www.westonmercury.co.uk

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