Newborn baby left dying alone at the Royal Free Hospital because doctors thought he had died
PUBLISHED: 14:19 17 March 2016 | UPDATED: 14:22 17 March 2016
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A newborn baby was left dying alone on a resuscitation table after doctors mistakenly gave him up for dead and medical staff ignored his gasps for breath, an inquest heard.
Baby Sebastian Sparrow revived himself an hour and a half after his parents were told by medics at the Royal Free Hospital that he had died.
But Sebastian was too badly brain damaged to be saved, and died two days later after being transferred to University College Hospital.
Coroner Mary Hassell was critical of several medical staff throughout last week’s inquest, and said that they must have realised the baby’s “agonal gasps” meant that he was “dying, and not dead”.
Sebastian was born by caesarean section on November 6 2013 after his mother, Sally Sparrow, experienced a prolonged labour.
He was expected to be a healthy baby as no problems had been detected throughout the pregnancy.
It was suggested during the inquest that he may have sustained brain damage during the caesarean delivery as it took three attempts by different obstetricians to deliver the baby.
In a statement, Mrs Sparrow, a solicitor, and her husband, Jamie, an accountant, said they were left with “no real understanding of what had happened” after the mistaken diagnosis of death.
A post-mortem was not performed, and doctors failed to report Sebastian’s death to the coroner, which Ms Hassell said was a clear breach of medical duty by doctors.
Sebastian’s parents were present throughout the 13 hours of medical evidence at St Pancras Coroner’s Court, but gave their evidence in a statement.
It was Mrs Sparrow’s first pregnancy, and Sebastian was full-term when she went into labour and was admitted to the Royal Free.
Sebastian was born “in a very poor condition”, which shocked the delivery team as there had been no complications detected prior to delivery. He was delivered “pale, floppy and with absolutely no tone”, according to medical staff, and was not breathing.
The crash team was called to theatre, and resuscitation attempted for 30 minutes before death was apparently pronounced, although doctors failed to call a time of death.
The baby was left on the resus table and medical staff offered condolences to his distraught parents as his mother lay on the operating table recovering from the caesarean.
Midwives went to dress and prepare baby Sebastian to be held by his parents, who were taken to a private room to wait for their son.
Half an hour later, they were told by a paediatrician that Sebastian was making “post death gasping actions” which were distressing even for medical staff to witnesses, and asked if they preferred to wait for this to pass before holding him.
His parents said: “Thinking that Sebastian was dead, and not wanting to make our distressing situation even worse, we chose to wait.
“Another hour passed, before the paediatrician returned to tell us that he didn’t understand what had happened, that neither he nor the other hospital staff had seen anything like it, but Sebastian had revived himself and was breathing unaided and had a regular heartbeat.”
However, the paediatrician told them that because of the intervening period of an hour and a half when Sebastian was thought to be dead, he hadn’t had any oxygen and his vital organs may have been damaged.
A transfer to a specialist neo-natal unit at University College Hospital was arranged, where he was given a new treatment, xenon gas, but his parents were told that Sebastian had severe brain damage, and that nothing could be done.
Mr and Mrs Sparrow said: “On November 8, treatment was withdrawn, and nature took its course.”
Sebastian died in his mother’s arms shortly afterwards.
Giving evidence, Dr Janet Rennie, a neo-natal specialist at UCH, said she believed Sebastian’s brain injury was probably caused by delivery attempts during the caesarean.
She said that the mistaken diagnosis of death had lead to further complications, such as organ failure and immune system shutdown.
When Sebastian died, Dr Rennie told the Sparrows that the cause of death had already been ascertained. They said: “On that basis we decided not to have a post-mortem, but to let Sebastian rest after such a short, traumatic life.”
Ms Hassell told Dr Rennie that not reporting Sebastian’s death to the coroner was “the wrong thing to do” under the circumstances.
Dr Rahul Chodhari was the most senior consultant paediatrician who assisted with resuscitation at the Royal Free before the decision to stop.
He said he “cannot remember” why it was decided not to call the coroner, when they mistakenly believed Sebastian had died.
Questioned by the coroner, Dr Chodhari admitted that he recognised there were “signs of life” in Sebastian 30 minutes after resuscitation attempts were stopped, but because he thought the likely outcome would be death or serious brain damage, he chose not to reactivate resuscitation.
He said he now accepts “wholeheartedly” that there were serious failings in Sebastian’s care, and that he would do things differently in the future.
Dr Chodhari said: “The fact that his parents weren’t with him at the time when he most needed them is something that is going to resonate with me for life.”
Two serious incident reports were compiled because of the mistaken diagnosis of death, but after their initial shock had passed, the Sparrows were left with more questions than answers, and their fight for the truth led to an inquest after a two and a half year wait.
The coroner will deliver her conclusions and make recommendations this week.