A doctor has broken down in tears recalling the 'systemic failure' after an infant died from sepsis days after being born.
Kingsley Olasupo was just ten days old when he tragically died at Royal Bolton Hospital on April 18, 2019.
The infant struggled to eat and regulate its own temperature and was admitted to the hospital's special baby care unit (SCBU) before being moved to neo-natal intensive care unit a day after.
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Doctors diagnosed the newborn with meningitis and sepsis, Manchester Evening News reports.
Midwives had to contact the on-call doctors three times before someone attended to the newborn, delaying his treatment and therefore his recovery, an inquest at Bolton Coroner's Court heard.
Doctor Kate Kewley, who was a senior registrar in her seventh year of paediatric training at the time, was the on-call doctor overseeing the ward on April 11, 2019.
She discussed her role tending to the infant and the 'systemic failure' of hospital staff failing to get the infant started on antibiotics sooner.
She was given a call by junior colleague Dr Salako to see Kingsley at the ward.
Once she arrived to the special baby care unit, Dr Kewley said she looked through Kingsley's medical notes.
But she was unable to find the comprehensive charts saying they were incomplete and incorrect in some places.
The court heard evidence that no meconium (a baby's first poo) was present during birth - even though it was.
The notes also failed to record Kingsley's temperature regulation problems, and inability to eat.
Based on the notes, Dr Kewley concluded that there was no risk of Kingsley having an infection, and his symptoms were down to prematurity.
She agreed to admit the infant to SCBU to monitor his feeding without needing to screen for an infection or start antibiotics.
Two other consultants had also agreed when presented the medical records used to make that decision.
Dr Kewley did discuss the possibility of an infection with Kingsley's family, but said it was more likely his poor feeding was down to being premature as this is a common problem faced by pre-term babies.
The thought that Kingsley could be suffering from an infection persisted in her mind, with the registrar later asking a nurse on SCBU: "How bad is he feeding? Do I need to screen him?"
On her next day on shift, April 12, Dr Seshadri, the consultant on SCBU, asked her to take blood samples after mum Nicola Daley said Kingsley's eyes had been moving strangely.
It was then that Dr Kewley truly believed Kingsley had an infection.
She told the court: "That was the point when I felt there was too much that we were potentially putting down to other things so I said 'should I screen him and give antibiotics?' and Dr Seshadri said to just take bloods.
"Dad was there and Kingsley's older brother was there as well so I updated him briefly at that point but obviously I just wanted to screen him and give him antibiotics so I inserted the canular and took blood gases.
"Kingsley was quite unhappy with me undressing him which made me more suspicious still of infection and I gave him a double dose of antibiotics - I thought giving him antibiotics on SCBU would be quicker than taking him to intensive care with the intention of taking him there once I'd done that."
Kingsley's condition began to worsen and doctors detected bleed on the brain.
By the time he was transferred to the neo-natal intensive care unit, a lumbar puncture was done which confirmed the tot had meningitis.
Staff tried to treat the newborn's infection with antibiotics stabilise his condition over the next few days, but on April 18 a brain scan showed that Kingsley's condition was "unsurvivable".
When Louise Green, the solicitor representing Kingsley's family, asked whether Dr Kewley would have decided to start antibiotics the day Kingsley was admitted to SCBU if she had a more comprehensive overview of his medical history, the now-consultant said she would.
Dr Kewley also stated that she believed paediatricians should have come out to review Kingsley on at least two prior occasions - once when low temperatures were recorded during the meconium observations straight after Kingsley's birth and again when a midwife raised concerns about his temperature regulation whilst he was in an incubator.
Alongside the confusing note keeping, staffing issues were also identified, with Dr Kewley saying "it wasn't uncommon'" that the maternity unit would be short a registrar, with one of the on-shift doctors having to pick up patients from the post-natal ward where Kingsley was admitted on top of their ward's patients.
Ultimately, she believed there was a "systemic failure" to take opportunities to treat Kingsley sooner, crying on the stand as she added: "I think there were dots with Kingsley's care that really should have been put together and I see it as a systemic failure and a personal failure that we didn't. We let him down, and we let you down, and I'll always be sorry for that."
Dr Seshadri also gave evidence today, supported by his own legal representative as he disputes the Serious Incident Report carried out by Bolton NHS Foundation Trust that concluded Kingsley would have survived if he had been given antibiotics earlier in his life.
Most of Dr Seshadri's dispute comes from the Trust's position that Kingsley picked up the infection at birth, as the consultant believes it was more likely the newborn became infected after a feeding tube was inserted on the SCBU.
Speaking about his objection to the report, he said: "We are in no way trying to defend ourselves, we want to find answers for ourselves and the family. We could not have said with 100% conviction Kingsley does not have an infection so the safer thing to do would have been to start antibiotics."
He instead outlined the idea that Kingsley was "colonised" by bacteria throughout his first four days in the hospital, picking up different species of mostly harmless bacteria as any other newborn does, which he believes is how Kingsley first came into contact with the Enterobacter cloacae - a bacteria that usually lives in the gut.
However, an event such as the insertion of a feeding tube would cause "some trauma", meaning it would be possible for this bacteria to enter the blood stream and cause an "invasive infection", meaning Kingsley would not have been unwell with an infection until after he had been admitted to the ward so there may have not been any opportunities to save him with earlier opportunities.
When asked by Miss Green, Dr Seshadri also accepted that it was possible that the bacteria which caused the infection could have been picked up through mum's frequent UTI's during pregnancy, or when Kingsley was exposed to meconium during birth, but he believed the feeding tube was the "most likely" trigger of the infection.
Despite his differing views to the Trust, Dr Seshadri still wishes he'd started Kingsley on antibiotics when he was admitted to SCBU, explaining that Kingsley definitely met the criteria for starting antibiotics - even if he's not certain whether the extra 24 hours would have made a difference as the bacteria which caused Kingsley's infection responds to a specific type of antibiotic which would not have been the first choice.
So far, the court has heard of several changes made at Royal Bolton Hospital following Kingsley's death, including a more comprehensive note system which includes the sepsis screening tool on every form to check every baby, with clear colour-coded point systems to show at what point concerns should be escalated to a paediatric doctor.
More evidence is set to come from experts brought in by the Trust to complete the Serious Incident Report about the outcomes of that and what lessons have been learnt since the incident.
The inquest continues.
