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Baby death sparks midwifery review
THE death of a baby after a promised home visit was missed has resulted in the Royal Free Hospital changing the way it runs its community midwifery team, an inquest was told.
Debora Potera died six days after birth from a rare infection which the Hampstead hospital’s midwifery manager had never in her 30-year career seen result in the death of a full-term baby.
A St Pancras inquest was told on Tuesday how the baby, whose parents lived in Belsize Avenue, Belsize Park, died from e.coli neonatal sepsis caused by bacteria picked up from her mother or the hospital during birth.
Earlier this year coroner Dr Andrew Reid adjourned the inquest into the baby’s death after evidence came to light that her mother, Lavdije Potera, had not had the follow-up care the parents were expecting.
The baby’s father, Bejtullah Potera, described how Debora was sent home the day after she was born and, after an initial home visit by midwife Olabasisi Shittu, a second one was missed.
Mr Potera, a food and drinks manager, told the inquest he and his wife had been worrying as their baby had not been washed since birth and they had not been shown how to do it.
They asked Ms Shittu to demonstrate but she declined to, on the grounds that Debora had gone to sleep, but she said someone would come and teach them the following day.
But that visit never took place, and, at the earlier hearing in April, the couple described desperately trying to get a midwife around to see them.
Mr Potera said: “I just explained the baby was crying all night and we had problems with breastfeeding. Also I said the baby hadn’t been washed. She said she was unable to help and that someone would come. No one came.”
Maternity ward matron Jude Bayly said the visit was missed because of an administrative error.
After Ms Shittu called the hospital to log her visit, a member of the team “misfiled” the family’s card by putting it to the back of the pile.
This pushed the family to the bottom of the list.
Ms Bayly admitted that a series of subsequent phone calls was lost in the system, but that as a direct result of Debora’s death – which she described as a “very sad case” – systems had been overhauled “to reduce the risk of this ever happening to another family”. Instead of cards, which she said left room for human error, a logbook has been introduced.
And instead of midwives “calling in” their visits, the five sets of teams now return to the hospital to enter them into the logbook personally, the inquest heard.
Similarly, all daytime phone calls go directly to a midwife with a bleeper and are entered into a logbook. Any concerns that are raised or advice given are now recorded.
Dr Reid accepted expert evidence that washing the baby would not have made a difference to Debora’s condition, which “rapidly deteriorated” over a period of hours on the morning of her death.
Recording a “natural causes” verdict, he said: “On the clinical evidence there is no link between these administrative errors and the natural cause of death, which can occur suddenly and has a very poor prognosis.”
He added that he did not need to write a Rule 43 report – which orders changes designed to prevent similar deaths – because the hospital “has taken steps to learn from this case and implement change to prevent similar fatalities”. |
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