Hospital 'failed' baby death family

THE parents of a baby that died less than an hour after being born were “failed” by a top Suffolk hospital where the standard of care fell short of what they should expect, an inquest has heard.

Greater Suffolk coroner Dr Peter Dean said there were a number of deficiencies in the level of treatment administered by Ipswich Hospital in the days leading up to the birth of Stuart and Merle Barbrook's first child.

He was speaking yesterday at an inquest into the death of their daughter Rowanne who died of E.coli sepsis shortly after being born on October 29 last year. Her twin sister Erin survived.

The hearing, which was being held at Suffolk County Council headquarters at Endeavour House, was told how staff at Ipswich Hospital failed to identify Mrs Barbrook as a high risk patient, even though she was pregnant with twins and her water had broken after 36 weeks and five days, which is classed as a premature birth.

An initial internal swab also failed to spot that Mrs Barbrook was carrying an E.coli infection and as a result she was not regarded as a priority and was not seen by a doctor for 43 hours.

A spokesman for Ipswich Hospital last night said an investigation took place immediately after Rowanne's death and significant improvements had been made to maternity services.

Recording a narrative verdict, Dr Dean also said that even if the infection had been spotted earlier, the outcome may not have been any different.

The inquest heard how Mrs Barbrook, who lives with her husband in Bildeston, Ipswich, was admitted to Deben ward at 12.15am on October 28 last year after her waters had broken.

Although she was a high risk pregnancy staff at the hospital failed to recognise this and an internal swab also failed to pick up that she he had an E.coli infection, a bacteria that occurs naturally in the bowels but in some forms can cause serious disease, especially if it infects the birth canal.

As a result Mrs Barbrook was not seen by a doctor until 8.20pm on October 29 - the night she gave birth to her twins.

Giving evidence, registrar Dr Reageev Singh, who was the first doctor to see Mrs Barbrook, said: “I reviewed the notes of the whole case as is my practice but could not see any signs that anything was wrong. I cannot say there is one point where the scans are normal and then become abnormal.”

Locum consultant obstetrician Mohammed El-Khadehm said: “On that particular day it was very busy and I remember there were three Caesarean sections. As a result, because she was not known as a high priority, these were carried out first. I spoke to the registrar and he told me she was doing nicely. There were no signs that anything was wrong. I told him if there were any concerns after delivery to let me know.”

At 9pm Mrs Barbrook was taken to the procedure room where she eventually gave birth to Rowanne at 11.05pm and her sister Erin at 11.08pm. Although doctors were able to save Erin, Rowanne was pronounced dead at 11.30pm.

A post-mortem of the baby found that she had died from an E.coli sepsis infection, which was present in the uterus at the time of the birth.

Recording his narrative verdict Dr Dean said: “I think it has been determined that Rowanne Barbrook died of E.coli sepsis following a prolonged rupture of the membrane.

“There is no evidence to suggest that anyone involved in the case acted in anything but good faith but clearly there were failures and Mrs Barbrook deserved a better standard of care than she received.

“On admission she should have been identified as a high risk pregnancy but this was not the case. As a result she was not seen for 43 hours and there were deficiencies in the level of supervision given.

“However there were rare circumstances as she was not showing any outward clinical signs of infection such as a rise in temperature, a rapid pulse and generally being unwell. It was a rare combination and no criticism of the individuals involved but clearly the system did fail her.

“What is less clear is if the outcome of these very sad circumstances would have been any different had the delivery been any earlier. Unfortunately the circumstances are such that we will never know.

“The infection had already taken a hold in a substantial way and baby Erin was able to survive and therefore I do not think a clear causal link between those failures and the tragic outcome can be established.”

In a statement issued by Mr and Mrs Barbrook after the inquest the couple said they hoped Ipswich Hospital would review its procedures in light of the findings.

The statement read: “The inquest has fully investigated how the chain of events that occurred led to Rowanne's death. It could all too easily have been an inquest into the deaths of all our daughters.

“In light of the verdict and the findings we sincerely wish the hospital reviews, and if necessary changes, how they care for expectant mums so in the future all mums-to-be can have the confidence that they will receive the best care and attention possible and that the risk of neo-natal deaths occurring in these or any other circumstances are minimised.

“The birth of our daughters should have been the happiest time in our lives but it turned into the worst ands we feel the hospital should do everything in its powers to stop this happening to any other couple.”

Ian Scott, Ipswich Hospital Trust medical director said: “When this very sad death occurred in October 2004, we expressed our sincere condolences to the family and I would like to re-iterate our condolences now.

“Senior staff working in maternity services undertook an immediate investigation into all the circumstances surrounding Baby Rowanne's death at the time. What they found was that better communication and more careful monitoring could, and should have been in place.

“There have been significant changes in maternity services in recent months and the issues identified in this investigation are being addressed.

“Childbirth is not risk free and while we are very thankful that sudden and unexpected deaths of babies are isolated incidents, we are determined to do everything we can do, to minimise the risks involved, but we will never be able to eliminate all risks.”