Baby died in dad’s arms after bungling hospital medics made FIVE major mistakes
A baby girl died in father's arms after bungling hospital medics made five major mistakes – and withdrew vital medicine for 60 hours, an inquest heard.
Jorgie Stanton-Watts died at 23-months-old after a series of failures meant basic medical care was not given correctly.
Failures included essential treatment being stopped at Kettering General Hospital for no apparent reason which meant Jorgie, who was born without a pituitary gland, would have survived, according to a medical expert.
The hearing was told information about the medicine was available on every A&E ward in the country and missing it was like "going into a church and missing the bible."
Shockingly, observation notes were made on pieces of scrap paper which led to inaccurate record keeping and also contributed to the tragedy at Kettering General Hospital, reports the Daily Record .
Additionally, blood tests were not carried out and expert advice was not sought despite her being a 'high risk patient in a high risk situation'.
Delivering his verdict yesterday, Northamptonshire coroner Philip Barrow said: "The hospital have openly accepted that there were various failings.
"In my judgement it's clear at least some of those contributed to the death of Jorgie.
"It means there was a gross failure to provide basic medical attention for someone in a dependant position who clearly needed it.
"I do find that neglect was made out.
"Jorgie died of the effects of dehydration and sepsis to which neglect contributed. "
Jorgie had been taken to the hospital following a minor infection on October 1, 2016.
Because of her condition, she was more susceptible to infection and was admitted to the Skylark Ward at the hospital.
But Northampton County Hall was told how a five hour delay in weighing Jorgie's nappies, meant that a fatal fluid imbalance was missed.
She was originally correctly administered intravenous hydrocortisone – but this was stopped after the first three doses.
Dr Richard Stanhope, said Jorgie should have had the full dose for four to five days before it was gradually decreased over the next four to five days.
He told the inquest this information was in the British National Formulary – a copy of which was in every A&E department and every ward in every hospital.
Mr Stanhope, who has over 40 years' experience as a paediatric endocrinologist at Great Ormond Street Hospital, said: "It's everywhere.
"You can't miss it. It's like going into the church and missing the bible."
Jorgie was seen by medical staff to be 'puffy', which Dr Stanhope said was the beginning of the problems associated with metabolic acidosis – a condition that occurs when the body produces excess acid.
Paediatric endocrinologist Jeremy Kirk, from Birmingham Children's Hospital said: "The decision to stop hydrocortisone was inappropriate.
"There were 60 hours were Jorgie was off hydrocortisone."
Jorgie collapsed on the evening of October 5 and was taken to Leicester Royal Infirmary but by then there was no effective treatment they could give to save her life.
She died in her dad Stephen's arms on October 8.
Mr Barlow recorded a cause of death of multi-organ failure caused by hyponatremic dehydration and sepsis.
He said that the three contributory factors were bronchiolitis obliterans, adrenal insufficiency and hypopituitarism.
During the inquest, medical and nursing staff took to the stand and admitted errors that had been made were 'unacceptable'.
Divisional head of nursing for paediatrics and neonates Simon Hardcastle said changes had been implemented on the ward since Jorgie's death.
He said: "I think the learning that has taken place has really helped with the changes that have been implemented.
"I think it's been taken very seriously and there's that wanting to ensure it doesn't happen again to anyone other child. I am assured of it, and I see it happening."
Jorgie's gran Zena Stanton, 68, told the inquest: "Now it is us, Jorgie's family's chance to say how we feel about what happened – how we have lived through a nightmare that will not go away.
"How the way the police conducted their investigation and made decisions without gathering what we thought were all the relevant statements.
"We put Jorgie into the hands of the people we trusted and one of our biggest fears now is if one of the other kids becomes unwell. Who do we trust?
"We feel throughout these investigations, one thing has been forgotten – our beautiful little sunshine died, and we watched her failing and no one was listening or acting on the clear visible signs of her failing.
"We are a strong, united family and what hurts one of us hurts us all.
"We are hoping by listening to us today and seeing our pain that this will have a bigger impact than any action plan that has been drawn up will do.
"We were ignored time and time again until we had to go above the staff on the ward to get action from someone we knew would listen and act. But by then we now know it was too late."
Mum Nicola Stanton, of Corby, said afterwards that the family was pleased that the coroner had recorded a neglect verdict.
She added: "This is what we wanted but there are no consequences for the medical staff who failed. I won't give up here. I'll continue to fight for Jorgie.
"We've had several other families in similar situations contact us already. We want to speak to them about their experiences."
Kettering General Hospital's Director of Nursing and Quality, Leanne Hackshall, said: "Following today's conclusion by the coroner we would like to extend our sincere apologies to Jorgie's family for the points in time when we could have done more to support her.
"Jorgie was a regular inpatient at Kettering General Hospital and our paediatric team supported her needs on many occasions working closely with specialists from Leicester Royal Infirmary.
"The events leading up to her death have been subject to extremely detailed reviews in order to identify what more the Trust could have done to support her treatment.
"Those reviews found there were aspects of her care and monitoring that could have been better and we fully accept that.
"As a result we have carried out significant extra training and reflection with our team to address all the issues raised and improve our processes for the close monitoring of children with complex conditions.
"We would like to emphasise that the Trust has worked very hard to learn all of the lessons that can be learned from Jorgie's tragic death.
"We would also like, once again, to offer our sincere condolences to her family."
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