A coroner has ruled that 'neglect' contributed to the death of a baby boy who suffered a brain injury while being breastfed in hospital.
Olly Vickers died four months after being born at the Royal Bolton Hospital. A coroner today (Friday) ruled that there had been 'a gross failure to provide basic medical attention' to him on the day of his birth.
Two midwives failed to supervise Olly over a 45-minute period while he was being breastfed by his mother, Emma Clark, for the first time. When they finally went to check on the baby, they found him 'floppy' and 'blue in colour'.
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A hearing at Bolton Coroner's Court heard Olly suffered a brain injury, which led to his death nearly five months later.
The inquest was told that Olly was born in 'good condition' on the morning of September 13, 2021, weighing 8lbs 6oz. Shortly after his birth, midwives Anne Maycroft and Danielle Woods took over the care of Ms Clark and her baby.
Ms Clark had wanted to breastfeed Olly so Ms Woods, a student midwife, helped her to position her son. She provided a pillow under Ms Clark's arm, which went against accepted practice, the inquest heard.
Ms Clark had suffered a tear during labour and Ms Maycroft began stitching the wound while administering gas and air pain relief. The hearing was told the midwives should have advised Ms Clark not to hold her son while she was being given gas and air, but they did not.
If Olly was to be allowed to continue being held by his mother then a risk assessment should have been carried out, which the inquest heard was not done.
As Ms Clark continued to breastfeed Olly, Ms Woods filled out medical records on a computer while Ms Maycroft repaired Ms Clark's wound. After she had finished, Ms Maycroft went to reposition Olly and found he had slid to his mother's side where his airway was being blocked.
When she picked Olly up, she found him 'floppy and blue in colour'. Attempts were made to resuscitate Olly before he was admitted to the neonatal intensive care unit.
An MRI scan taken when Olly was four days old showed he had suffered a 'significant acute hypoxic brain injury'. He spent the next few months in hospital before being allowed home with his family on January 17.
However, Olly returned to hospital in February after suffering a high temperature and vomiting. He was diagnosed with a chest infection and died two days later, the inquest heard.
Pathologist Dr Gemma Petts gave Olly's cause of death as 'bilateral severe acute pneumonia', which she said was contributed to by 'grade three hypoxic-ischaemic encephalopathy'.
Recording a conclusion of 'neglect', coroner Peter Sigee ruled that Olly's brain injury had 'more than minimally contributed to his death'.
He said there had been 'a gross failure to provide basic medical attention' and that had Olly been observed properly or the stitching to Ms Clark's tear delayed, his death would likely have been avoided.
"Olly would not have died when he did if this neglect had not occurred," he added.
After hearing from Louise Tucker, a consultant midwife at the Royal Bolton Hospital, that lessons had been learned from Olly's death, the coroner said he was satisfied that there was 'no longer an ongoing risk to life'.
Speaking following the hearing, Ms Clark, from Little Lever, said: “Olly was so strong and brave throughout his short life. He was such a funny and loving baby who filled our hearts with love. We will always treasure the memories we made with our precious boy.
“Words cannot describe the pain of losing him, it’s there every minute of every day. For this to be avoidable if all the guidelines had been followed compounds everything. We question whether if we’d gone to a different hospital on a different day Olly would still be here.
“We want to raise awareness of the need to listen to parents, to follow the guidelines, which are there for a reason, and to ensure staff are trained in the importance of these issues. Olly was our world and losing him is something we will never fully recover from. Lessons being learned from his death is the only hope we can cling on to.”
Jodie Miller, a solicitor representing Olly's family, added: “This is a harrowing case and has taken an unimaginable toll on Emma and Michael. We feel a finding that Olly’s death was contributed to by neglect was the only conclusion that could be reached on the evidence.
"Olly was born a healthy baby boy and Emma and Michael were full of joy and excitement about the future the family had to look forward to. However all of that was taken away from them when the safety guidelines that exist to prevent this type of incident from occurring were not adhered to.
"All we can hope is that the action plan put in place by the trust ensures that no other families have to go through what Emma and Michael have.”
Tyrone Roberts, Chief Nursing Officer at Bolton NHS Foundation Trust, said: “Our thoughts and sympathies remain with Olly’s family following the tragic loss of their son. Since Olly’s death, we have implemented a number of changes to minimise the risk of such a tragedy happening again.
"We fully accept that the care we gave Olly and his family was not acceptable. Whilst nothing we say can take Olly’s family’s pain away, by continuing to do everything we have outlined, our expectation is that no family will have to experience this in future.
“We are incredibly sorry that these mistakes were made.”
