Coroner criticises Royal Free Hospital doctors over baby mistakenly thought to be dead
- Credit: PA WIRE
A coroner has concluded it is impossible to say how a baby who was mistakenly declared dead and left dying alone in The Royal Free Hospital developed the brain haemorrhage which ultimately killed him.
She said that doctors’ refusal to move from their “firm view” that Sebastian Sparrow had died, despite evidence to the contrary, was “the most extreme example of positional bias that I have ever seen”.
Mary Hassell, senior coroner for inner north London, said because baby Sebastian’s death in November 2013 was not reported to the coroner at the time and no post-mortem was performed, she could not now “plug the gap” as to what caused the damage to his brain.
As reported previously in the Ham&High, Sebastian was delivered by caesarian section after his mother, Sally Sparrow, experienced a prolonged second stage of labour.
Although believed to be a healthy baby prior to delivery, Sebastian was born “pale, floppy and not breathing” and resuscitation was immediately begun.
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Just 30 minutes after birth, resuscitation was abandoned as medics believed Sebastian to be clinically dead, and condolences were offered to his distraught parents.
He was later found by midwives to be “pink and with a spontaneous but irregular heartbeat” and the news had to be delivered to his bewildered mother and father that their son was still alive.
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But Sebastian was severely brain damaged, and despite being transferred to a specialist neo-natal unit at University College Hospital, nothing could be done to save him.
He died in his mother’s arms two days later.
Reaching a narrative conclusion, Ms Hassell said that two consultant paediatricians who found Sebastian making gasping sounds and shudders should have realised the baby was “in the process of dying, and not dead” and ought to have made a plan of care for him.
During the inquest, it was suggested that obstetricians could have caused Sebastian’s brain damage during the caesarian, as it took three surgeons repeated attempts to deliver the baby.
The Sparrow’s solicitor suggested that the junior doctor and the registrar who tried to deliver Sebastian unsuccessfully could have caused the brain damage with their attempts to flex the baby’s head, before the consultant obstetrician took over.
But the junior obstetricians both denied using force in their delivery efforts, and suggested that Sebastian could have had an underlying medical condition.
Finding the medical cause of death to be brain injury caused by lack of oxygen and a brain haemorrhage, Ms Hassell said that the reason for the bleed to Sebastian’s head remained unclear.
She said: “It could have been caused by trauma or by the delayed second stage of labour.
“Neither is particularly likely, but each is possible.”
She said of the medical staff who treated Sebastian at The Royal Free: “I don’t think they intended to be unkind, but I don’t think they were thinking in the right way.”
She said she realised her determination might leave his parents, Sally and Jamie, feeling unsatisfied after their long wait for answers.
But Ms Hassell said that in her lectures, she would talk about this case when teaching students and medical staff about the dangers of “positional bias” - a refusal to shift from an original diagnosis.
Further medical failings
The coroner quizzed two consultant paediatricians from The Royal Free over their failure to call a time of death, and then to report what they thought was a death to the coroner, which she said was a clear breech of their medical duty.
Dr Shye-Wei Wong was present in theatre when Sebastian was born, and began resuscitation whilst a crash team was called.
He formed the opinion that Sebastian had died 29 minutes after birth, as he had been unable to detect a heart beat during that time.
Under examination, he said the baby had gasped just once, three minutes after birth.
Asked by Ms Hassell why he had failed to call a time of death, he said: “I’m not sure why.
“I didn’t get the chance, because I went to speak to the parents, and to Miss Evans (the consultant obstetrician) to discuss what had happened.”
Dr Wong said he did not report what he believed to be a death to the coroner because Sebastian’s parents did not want an autopsy.
But Ms Hassell said: “It’s entirely the wrong way to go about things to ask mum and dad if they want to report the death to the coroner.
“It is the coroner’s decision whether to have an autopsy.”
Quizzed over why he ignored the concerns of midwives, who witnessed gasps and shudders from Sebastian after he was declared dead, Dr Wong said he deferred to the explanation of his senior colleague, Dr Rahul Chodari, that these were “aganol gasps”.
Ms Hassell told him: “Aganol means prior to death.”
Dr Wong said: “It seems obvious now that Sebastian was dying rather than had died, but I had never heard a heartbeat from him.”
Ms Hassell said: “It seems desperately callous. But you don’t come across as callous.
“You had one idea, and you just stuck to it.”
Dr Wong replied: “I think that’s a fair assessment.”
Ms Hassell also criticised the decision by University College Hospital not to report Sebastian’s death to the coroner when he died there on November 8.
Dr Janet Rennie, a neo-natal consultant who cared for Sebastian, said she did not report the death to the coroner because she considered she had already ascertained the cause of death.
But Ms Hassell told her that was clearly the wrong decision, given the circumstances.
Sebastian’s parents, Sally and Jamie, said they had decided not to request an autopsy at the time because they accepted Dr Rennie’s judgement that the cause of death was known.
They said: “We decided to let Sebastian rest, after such a short, traumatic life.”
Royal Free Apology
A statement from The Royal Free Hospital after the inquest into baby Sebastian Sparrow’s death at St Pancras Coroner’s Court said: “We would like to apologise and express our deepest condolences to Sebastian’s family.
“We carried out a full and thorough investigation and sought independent verification of our findings. As part of this investigation we have reviewed our processes and policies and in similar situations in future, the patient will be cared for by a member of staff in an appropriate setting.
“We note the findings of the coroner, who did not find fault with our reporting of, or investigation into, this tragic event.”
Two serious incident reports were launched after the death, but Sebastian’s parents found these to be inadequate and sought legal advice to finally bring about an inquest.