A devasted mother is to take legal action against a hospital following the death of her two-month-old baby. Jodie Stubbs son Iva-Jaylon Champion Weekes could have survived if it hadn't been for a string of failures by Royal Stoke University Hospital, a coroner ruled.
Iva-Jaylon was born prematurely at 24 weeks and six days gestation, weighing just 740 grams and as tiny as a hand. But his mum said he was getting stronger by the day, Stoke on Trent Live reports.
An inquest heard yesterday that Iva suffered a rare complication from the procedure. The signs he was deteriorating weren’t picked up early enough. The catalogue of failings included:
- No documented evidence that blood pressure checks were carried out between 6am and 9pm. That meant staff thought his raised heart rate was due to pain from the procedure and didn’t see the wider picture. He was given increased morphine and oxygen, yet didn’t improve;
- No immediate medical review of his condition was carried out when he returned to intensive care;
- A blood gas reading at 6.30pm was abnormal, with signs of acidosis. Yet concerns were not ‘escalated to medics’ until a second blood gas result at 9.15pm.
By the time hospital staff at Royal Stoke University Hospital realised he was critically ill, he would have died within 30 minutes without urgent treatment. X-rays confirmed he had a bowel perforation and medics snapped into action.
North Staffordshire assistant coroner Sarah Murphy said: “It was all hands to the deck to try to save baby Iva.”
The hospital arranged to have him transferred to Alder Hey Children’s Hospital, in Liverpool, for lifesaving surgery. But the transfer was delayed as the neonatal transport team was tied up with another patient.
Iva was taken to Birmingham Children’s Hospital instead. He arrived in the early hours of April 9 and died a short while later after a cardiac arrest. His cause of death was due to bowel perforation and peritonitis, with long-term complications of extreme prematurity.
Royal Stoke consultant neonatologist Dr Lee Abbott, who wasn’t directly involved in Iva’s care, told the inquest there had been clear missed opportunities. Asked how often blood pressure measurements should be taken, he said in the case of surgery, he would have recommended every ’15 to 30 minutes’.
Although Dr Abbott said the transfer delays wouldn’t have affected the outcome, he has since worked with the transport team to improve the referral process.
Dr Saravanan Jayachandran carried out a review for Royal Stoke following Iva’s death. He said: “The principal finding was there was a failure in recognising the clinical deterioration in the baby early on.”
University Hospitals of North Midlands NHS Trust is now implementing a 13-point action plan, which includes additional staff training, a new standard operating procedure, and an audit of neonatal cases.
Recording a narrative conclusion, Ms Murphy said the death was due to a very rare complication of laser therapy, contributed to by neglect. She added: “I do find that the failings identified led to, or contributed to, the death.”
Speaking after the hearing, Jodie, aged 37, said: “The verdict is a bit of justice. I’m planning to take legal action now.”
