An on-call paediatrician did not assess a premature baby but instead told a concerned midwife to "put a sleepsuit on" him when she raised concerns that his temperature was still extremely low despite time in an incubator.
Kingsley Olasupo was born prematurely at Royal Bolton Hospital on April 8, 2019, alongside twin sister Princess. Although Princess was quite healthy, taking well to life outside the womb, Kingsley had a low body temperature and trouble feeding from the start of his life, with midwives putting the youngster in an incubator to help raise his temperature.
However, when he was still quite cold the next evening, and still feeding poorly, concerned midwife Nadine Wilson phoned the on-call paediatric doctor, who told her to put a babygrow on the tot and make sure he was wrapped up when leaving the incubator, an inquest has heard. Just over a week later, on April 18, Kingsley tragically passed away after being diagnosed with bacterial meningitis and sepsis.
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The first day of the five-day hearing at Bolton Coroner's Court today (Monday) heard evidence from midwives about the first few days of Kingsley's life before April 11, when the youngster was transferred from the post-natal ward, where healthy mums and babies are sent after delivery, to one of the neo-natal units for more specific care.
It heard concerns raised by midwives and the family's solicitor that Kingsley was not initially assessed daily by a doctor, despite his poor health and the fact that he was showing a number of risk factors.
Kingsley was cold after birth and was at risk of higher infection
Midwife Amy Leigh was the first to give evidence, after she'd seen Kingsley just a few hours after he was born in delivery suite six at the hospital. She told the court the tot was cold when he was weighed at 8.15am, just 35.6C, so she wrapped him in fresh, dry towels and blankets and put him in an incubator.
As meconium, a newborn's first poo, was present when Kingsley was born, he had to have hourly observations as this puts a baby at higher risk of infection, especially when combined with the fact Kingsley was born premature, at 35 weeks and four days, and had a very low birth weight at under the 10th percentile.
Kingsley also fed very poorly at first, the hearing heard, with dad Tunde Olasupo trying to feed his son for a while, managing 5ml before Miss Leigh took over and was able to feed him another 5ml. He managed a "good" amount of feed at 12pm, but took half an hour to do so which is quite slow for a newborn. She put this down to him being hypothermic.
As Kingsley's other observations were normal, Miss Leigh did not raise his low temperature with a paediatrician as the policy at the time made her believe she would just be told to incubate him, so she decided to try the method and see if it helped. The infant and his sister were then transferred to the post-natal ward at 12.45pm.
Statements from post-natal midwives Maria Lawson and Lucy McCann were read out in court outlining their involvement with the infant, with Ms Lawson confirming Kingsley was doing well after he was brought to the unit, before transferring his care to Ms McCann, who saw the tot's temperature vary between perfectly normal readings and slightly low throughout the night.
'They should have come and checked the baby out'
Ms Wilson took over Kingsley's care the next morning, checking his temperature and feeding throughout the day. At around 6.20pm, after becoming concerned about a slow feed and low temperature, she rang the on-call paediatrician to see if he could come and review Kingsley. The doctor did not come out to see him, and instead advised her to clothe him properly.
She told the court: "At 6.20pm he'd only taken 10ml of feed and his temperature had dropped again so I adjusted the incubator and contacted the on-call paediatrician to discuss Kingsley. They didn't come to assess... I felt like they should have come and checked the baby out.
"To my documentation and recall, they thought his temperature was dropping because he was coming out of an incubator without any clothes on, so said to put a sleepsuit on so when he came out of the incubator he would be warm and maintain his temperature better."
When asked, she said she was not reassured by this advice but did not escalate the incident higher, instead trying the advice to see if it helped before contacting the on-call team again. As her shift ended shortly after this conversation, Ms Wilson handed over the advice to the night midwife, before coming back in the next day to see that Kingsley's temperature had increased and he had been feeding better overnight.
Although his temperature had stabilised on April 10, Kingsley still had trouble feeding, proving that his issue wasn't related to being hypothermic. But his poor feeding was still not raised with a paediatrician - something which Ms Wilson admitted she should have done with hindsight when asked in court. She did, however, start a feeding chart with Kingsley's mother, Nicola Daley, to monitor how much Kingsley was eating.
Kingsley only seen by doctor at third time of asking
That evening, Jane Westhead took over Kingsley's care, and was almost immediately told by Nicola that the infant wasn't feeding well. After several observations done by Ms Westhead and another midwife, who covered Ms Westhead's break in the early hours of the morning, staff could see Kingsley was struggling with maintaining his temperature again, and was feeding poorly again.
Ms Westhead contacted the on-call neo-natal paediatrician to review Kingsley at around 6.15am but the doctor was busy with other patients and said he would not be able to see Kingsley before the end of his shift. He said that the youngster should be reviewed and weighed by a member of the day staff. Although it was up to the doctor to pass on this information to the day paediatrician, Ms Westhead alerted her morning colleague to the conversation at handover.
However, it wasn't until around 1pm, when the morning midwife contacted paediatrics again to raise concerns about poor feeding for a third time, when Kingsley was actually seen by a doctor. It was decided that Kingsley would be moved to the neo-natal unit for treatment.
All three midwives admitted there was some confusion about when a baby needed to have their care escalated to a paediatrician, as at the time the midwifery department at the Trust was not using the Newborn Early Warning System (NEWS) forms which clearly outlined an escalation policy - despite there being a hospital policy in place dictating these should have been used.
The forms used at the time made reference to escalating a baby to a paediatrician in the neo-natal unit, but did not give any indication on when it would be appropriate to contact one of the doctors, meaning midwives had to rely on their own judgement. They both went on to explain that new forms were now used by the Trust, with the NEWS system and a sepsis chart clearly outlining at what point concerns about a baby should be identified to a paediatric doctor.
Miss Leigh also explained that midwives on the labour ward now screen every baby for early warning signs of sepsis. The sepsis screening tool that used to only be readily available under cards relating to caring for a mother who had tested positive for group B strep, even though it was applicable to a wider range of mums and babies, was now readily available on every form, the hearing heard.
National Institute for Health and Care Excellence (NICE) guidelines at the time said two or more non-red flag risk factors should indicate to healthcare staff that babies need to be screened for infections and started on antibiotics straight away, something that was missed in Kingsley's case despite him showing five of these risk factors - prematurity, feeding poorly, meconium present at birth, temperature issues, and a birth weight below the 10th percentile. These new forms also help to identify how these non-red flag factors can, when presented together, be an indication of something more serious.
Louise Green, a solicitor representing Kingsley's family, raised concerns about the way the Trust followed guidelines that stated Kingsley should have been seen daily for review by a paediatrician, as none of these reviews took place until he was transferred to the neo-natal unit - a fact not picked up on by midwives on the post-natal ward. Evidence about how this practice was missed will be heard later in the week.
Today's evidence also heard from Doctor Melanie Newbould, a paediatric pathologist based at the Royal Manchester Children's Hospital, who listed Kingsley's cause of death as 1A: multiple organ failure, extensive cerebral necrosis and brain swelling, and 1B: bacterial meningeal encephalitis and bacterial sepsis caused by Enterobacter cloacae. This means the tot died when his organs failed and his brain tissue began dying due to the meningitis and sepsis infections.
Two photos of baby Kingsley in pristine white frames were handed over to the coroner at the start of the inquest, with dad Tunde clutching the frames in his arms as the family left for the day. There were 12 main concerns raised by Tunde in a written statement made the court, which was read aloud by Mr Sigee.
These included whether Kingsley should have been transferred to a specialised children's hospital, whether a blood test should have been performed earlier, and whether Kingsley would have had a better chance of survival if the infection had been picked up sooner.
The inquest is set to last for five days at Bolton Coroner's Court. Proceedings continue.
