Healthcare practitioners not to blame for Freddie’s death, says inquest

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An inquest into the death of a premature baby from Bury St Edmunds has found no evidence that healthcare practitioners were to blame.

Freddie James Wheeler-Bridges was delivered by emergency Caesarian section at West Suffolk Hospital on September 20, 2011.

His mother was showing signs of pre-eclampsia, a condition she had also suffered with her daughter Ruby, who was born prematurely at 25 weeks, in October 2010, and died aged six months.

Freddie was delivered at 31 weeks and six days and weighed 3lbs 7oz.

He died in Addenbrooke’s Hospital, in Cambridge, on September 29, 2011, at nine-days-old.

The inquest, which started yesterday and concluded today, gave ‘great weight’ to evidence suggesting Freddie could have suffered a ‘healthcare induced injury rather than a natural illness’ because of a cannula that was inserted incorrectly, into his liver, at West Suffolk.

It heard yesterday that Dr Flora Jessop, the pathologist who carried out Freddie’s post-mortem examination, found his liver to be ‘strikingly abnormal’.

“I reviewed all the findings of the infection screens to see if there was a significant infection that could explain why Freddie was so ill and there was no evidence of that,” she said.

She told the inquest that she enlisted the help of specialists at King’s College, London, which has the only paediatric liver centre in the UK.

In concluding Dr Jessop’s evidence, Suffolk coroner Dr Peter Dean said this was the point at which concerns were raised over the possible ‘introduction of something’ due to the misplacement of the cannula and the need to review notes paying attention to cannula positions.

Dr Alex Knisely, consultant in histopathology at King’s College, said on examining Freddie’s liver he found ‘different regions of damage’ of different types and ages.

The inquest heard how Freddie was born with an enlarged heart, as well as anaemia and jaundice.

He underwent a blood transfusion and within four hours of birth developed respiratory problems.

“Without knowing Freddie’s history of heart disease, I said I think you really need to consider the possibility that there was a catheter problem,” said Dr Knisely.

Of the misplacement, he said: “Although ill before, this could have made him substantially worse and lessened his chances of coming back from it.”

Dr Satyanarayana Chavakula, registrar on the neonatal unit the day Freddie was born, told the inquest he was unable to withdraw blood through an umbilical vein catheter (UVC) in Freddie, despite it ‘flushing well’ with saline.

Dr Martina Noone, consultant in charge of the special care baby unit the morning Freddie was born, said: “I think there’s no question the first cannula was in the liver. It was removed. Nothing was infused through it.”

The inquest heard how the insertion of a cannula was a’ blind procedure’ and the only way of checking it was in the right place was with an X-ray.

Dr Rebecca Tibbott, consultant registrar in paediatrics at West Suffolk, told today’s inquest she ‘started fluids’ through a second cannula ‘a couple of minutes before’ she had seen an X-ray, which later confirmed it was in the right place.

“It’s not uncommon in an emergency situation to use the line before you see the X-ray,” she said.

The inquest also heard that staff nurse Rachel Farr had not updated Freddie’s care plan and had written a retrospective note saying the first UVC was not to be used.

She told the inquest she was ‘the only one who looked after Freddie during that day’ and that the UVC was removed by the time she handed over at the end of her shift, so nothing could have been administered through it.

“I’m sorry that it’s caused confusion, she said.

Dr Sue Broster, consultant neonatologist at Addenbrooke’s, said: “I still remain concerned that there was an underlying metabolic condition we’ve still not got to the bottom of.”

She said she was sorry Freddie’s parents, Jamie Bridges and Amy Wheeler, were still ‘without answers’ and offered to work with them and the hospital’s genetic and metabolic teams to try and find out more.

In delivering his verdict, Dr Dean said the cause of death previously recorded, neonatal hemochromatosis (a rare and severe liver disease), was not supported by the medical evidence now available and could therefore not stand.

He said there was no evidence anything other than saline had been used in the misplaced cannular and evidence showed the second one, although used before an X-ray was seen, had been in the correct position.

He said: ““It seems likely that whatever process or processes were going on with Freddie, there was an underlying problem which would have been masked in uterus, but whatever underlying problems there were clearly became unmasked at birth with the loss of that life support system provided by the mother’s circulation.”

He concluded that Freddie died from multi organ failure (cause undetermined) with prematurity as a contributing factor.

Offering a narrative conclusion, he said: “Freddie died from multi organ failure, the cause or causes of which could not be established, following premature delivery.”