Senior staff at a hospital trust “absolutely have learned” from the death of an infant who was showing subtle signs of infection - and now use his case as a learning tool.
Kingsley Olasupo was ten-days-old when he died from bacterial meningitis and sepsis at the Royal Bolton Hospital on April 18, 2019. There had been a “systemic failure” to recognise that the infant was showing subtle signs of infection in his first four days of life.
The tot, born at the hospital with his twin sister Princess, was premature at 35 weeks and four days, had struggled to maintain his temperature, and was struggling to feed. Meconium, baby’s first poo, was also present at his birth - a risk factor for infection.
READ MORE: Doctor breaks down in tears as she recalls 'failure' that led to death of tragic baby
Jackie Smith, governance lead at the Bolton NHS Foundation Trust gave evidence on the third day of the inquest into Kingsley’s death, Wednesday April 28, at Bolton Coroner’s Court.
She outlined several steps the Trust had taken since Kingsley’s death to ensure an incident like this never happened again, including moving baby notes onto one form - a Transitional Care Observation and Assessment Tool (TCOAT).
This new form is colour-coded and is intended to be an “aide-mémoire” - a memory aid - to help nurses clearly see when a baby is showing several non-red flag signs of infection, and when these minor concerns should be escalated to a doctor.
There was also a new process of escalating a baby to a doctor, with a more formal process involving a written form replacing informal phone calls so midwives have to detail their exact concerns, making it easier for doctors and midwives to clearly understand what the issues with a baby are and how they’re going to be managed.
The post-natal ward now has a dedicated tier one - usually a junior doctor or a senior nurse practitioner - and a registrar. A consultant will also make daily ward rounds for any babies that the two doctors are concerned about. Babies needing “transitional care” - an elevated level of care than healthy babies on the postnatal ward - will also be clearly identified on a whiteboard, with one dedicated set of notes carried out by midwives and doctors who see that baby on the postnatal ward.
Specific training is also being delivered to maternity staff around the subtle indicators of infection that Kingsley showed, with Miss Smith confirming that Kingsley’s case was now being used in training to show how subtle infection signs can be.
Miss Smith stressed to the family: “It has been a really really difficult case and we absolutely have learned from this and put lots of measures in place to try and ensure that these gaps are not missed going forward.”
Concerns were raised by Louise Green, the legal representative for Kingsley’s family, around induction, as the hearing previously heard Dr Kate Kewley was unable to access all of Kingsley’s medical records as she had only been at the hospital for two months and didn’t know where to look for his notes.
Miss Smith was unable to answer whether the induction process adequately showed doctors where to find notes, but did say she would take that back to the Trust and investigate further.
The inquest, which was listed for five days, has now heard all evidence, with coroner Peter Sigee now hearing submissions from the legal representatives about what conclusion he should consider, and whether a report should be issued to prevent future deaths.
Miss Green has urged the coroner to consider whether there was any element of gross negligence involved in Kingsley's care, outlining both systemic and personal failures made by practitioners throughout the first four days of Kingsley's life, including the failure to screen him for infection, failures to escalate his care effectively, and substandard documentation about Kingsley's health.
Stephen Evans, the legal representative for the Trust, argued that any gross negligence finding has to extend past a simple failing by a professional, and that the failures have to be deemed gross negligence based on the presentation and need of the patient - not their eventual outcome.
Mr Sigee has now risen to consider his conclusion, which is expected to be returned later today, Thursday. A discussion about whether a prevention of future deaths report is necessary will take place after he has returned his findings, with a decision expected to be reached later this afternoon or Friday, depending on the length of submissions.
Proceedings continue.
