A TROWBRIDGE couple hope to discover if a mistake by doctors at a Bristol hospital led to the death of their four-day-old baby at an inquest.
Sarah and Andrew Goodall of Clarks Place, are attending the two-day inquest of their daughter Abigail at Flax Bourton, near Bristol.
On Wednesday the hearing was told that during Mrs Goodall’s pregnancy, doctors could only find three parts to Abigail’s heart, which resulted in the couple having to go to St Michael’s Hospital to deliver.
Abigail was born on October 24 last year through an emergency caesarean.
Assistant coroner Robert Sowersby was then told in the days that followed, Abigail’s health deteriorated. While on Neonatal Intensive Care Unit she was incubated and had two lines inserted to provide nutrients and fluids.
Mrs Goodall, a support worker with young adults, had a statement read out on the first day of the hearing.
She said during her pregnancy: “Doctors explained that Abigail’s heart was not normal.
“I felt that Abigail was a very special baby and I was very excited about her being born.
“When she was born, she was brought to the top of the bed and I was able to see her and stroke her head. Andrew then was able to see her and take some photos to show me and we were very proud parents.
“When I saw Abigail at around 1pm she had lines in her and no one told me.”
Mr Sowersby then heard evidence about why an arterial line and a venous line were inserted into Abigail in order for them to monitor her bloods.
Witness statements were read by several doctors caring for Abigail during her stay on the neonatal ward at the children’s hospital, including Dr Johnathan Davis, a consultant on NICU.
He said that these lines must be positioned close to the heart in order for them to reach the widest part of the artery and the placement is checked by an x-ray – something which was believed to have been misinterpreted.
Dr Davis said based on the response from the radiologist, they pulled back the arterial line instead of the venous one which was later found to have its tip within Abigail’s heart allowing Total Parenteral Nutrition fluid to gather in the heart’s lining.
Unbeknown to this fact, the doctors continued their standard procedure of resuscitation on October 28 which is when Abigail died.
“The lines are quite hard to see on an x-ray,” he said.
“I was satisfied that the right things were being done.
“There would have not been anyone available to do an echocardiogram to check the lines.
“I do not think that was the right thing to do in resuscitation because to carry out an echocardiogram, it would have meant that the person keeping Abigail’s heart going would have had to stop.”
Abigail was found to have suffered with pulmonary atresia – where the pulmonary valve does not form properly – but it was later found through a post-mortem that she also had cardiac tamponade – pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac of the heart known as the pericardium.
Mr Sowersby brought up the concern of why the arterial and venous lines are difficult to distinguish through an x-ray.
The hearing was told Abigail was taken to Great Ormond Street for a post-mortem, which Mrs Goodall had agreed to after meeting with doctors.
Pathologist Michael Ashworth, paediatric consultant at Great Ormond Street, found the level of fluid within her pericardium, the sac of fluid within the heart, Abigail had 18ml instead of normal levels of 1-2ml.
“It is an extremely unusual finding and 18ml is a lot for a heart this size but Abigail had an abnormal heart to start with.”
He also found traces of E. coli in her blood and lungs which he attributes to the week-long wait for the post-mortem, however Dr Davis believes in hindsight this could have been the reason for Abigail’s sudden collapse alongside the cardiac tamponade which they were unaware of.
Jan Dudley, part of the Clinical Governance Committee at St Michael’s Hospital who carried out an investigation into Abigail’s death, produced a report dated back in March.
In care and service delivery problems, Mrs Dudley said the misinterpretation of the x-rays contributed to the removal of the wrong line but also the lack to routine reviews of these x-rays by consultants.
“Having a process by way of three of four safety layers is something that is recognised in the NHS and if one of those layers is stripped away we increase the risk of those situations,” she added.
Mrs Dudley said the root cause was misinterpretation of the x-rays and added that within the report, they have outlined lessons learnt including tightening up on recognising catheter positions which is currently ongoing.
The inquest continues.