A newborn baby girl died after suffering a cardiac arrest caused by a rare medical condition, an inquest has heard.
A coroner was also told that a hospital blunder led to Naomi Dobrin being given a calcium overdose, but that it did not cause her death. The baby girl was just a day old when she tragically died at the Royal Oldham Hospital on August 29, 2021.
An inquest at Rochdale Coroner’s Court yesterday (Wednesday) heard she suffered an airflow issue known as bilateral tension pneumothorax, which caused her to suffer a cardiac arrest.
The hearing was told that shortly before her death, medics had mistakenly given Naomi three times the intended dose of calcium chloride. A doctor prescribed the medication after tests revealed the baby girl had a reduced calcium level.
However, the inquest heard a "mathematical error" led to Naomi being prescribed a 6.6ml dose - ten times the intended amount of 0.66ml. A nurse administered 2ml of the medication before stopping when she noticed the "unusually large" amount within the syringe.
Shortly after receiving the dose, the inquest heard that Naomi collapsed and was found unresponsive with no heart rate. Medics attempted to resuscitate her, but she was later pronounced dead.
Dr Simon Mitchell, an expert neonatologist who reviewed the case, said he did not believe the prescription error had caused Naomi's death. He said the dose initially intended for Naomi was “small” and while she ended up receiving more than three times that, the amount still fell within a “reasonable” range, according to national guidelines.
Dr Mitchell explained that Naomi was suffering from tension pneumothorax, a common side effect of being on a ventilator. He said the condition, in which air is trapped in the chest, would have caused her to go into cardiac arrest.
Letisia Dobrin, Naomi’s mother, had earlier told the inquest that she gave birth to her daughter on August 28, 2021, following a "normal pregnancy".
Naomi was delivered in "good condition" but began showing "signs of respiratory distress" less than 20 minutes after her birth. She was taken to the hospital's neonatal intensive care unit, where she was incubated and put on a ventilator to help her breathe.
Ms Dobrin said she and Naomi’s father, Ionut Holea, went to see their daughter that same day and were told she had "swallowed some fluid" during pregnancy but "would be fine". Dr Mitchell said Naomi was believed to have been suffering from meconium aspiration syndrome, a condition caused when a baby swallows its own faeces while in the womb.
Naomi was also given medication and her breathing was noted to have improved by the following day, the inquest heard. However, she went into cardiac arrest and died that afternoon.
Ms Dobrin, who has two other children, told the inquest she was "not the same person" following her daughter’s death.
The inquest also heard from Detective Inspector Damian Threader, of Greater Manchester Police. He said a police investigation into Naomi's death had found "no causal link" between the prescription error and Naomi's death.
The inquest continues today.
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