Baby died after catheter ‘wrongly inserted’ into stomach causing deadly sepsis
A baby died after a catheter was wrongly inserted into his stomach by a junior doctor, an inquest heard.
James Barnes developed sepsis after nutritional fluid was pumped into the wrong area of his tiny body.
The premature baby, who was born eight weeks early at 32 weeks, died of E-coli sepsis just six days after his birth.
Doctors said the umbilical veinous catheter (UVC) which was meant to help his condition had been wrongly inserted into his abdomen.
An inquest heard the catheter was inserted by a registrar working at the neonatal unit at the Medway Maritime Hospital in Essex on April 24 last year.
But the catheter, which was inserted in his left portal vein, was incorrectly placed in his stomach and may have caused an injury to the baby’s liver.
It was later spotted on an x-ray removed 48 hours later but by James’ condition had deteriorated massively.
Seriously ill, a decision to taken to transfer him 50 miles away to the Royal Sussex Hospital in Brighton but he died shortly after arrival.
Dr Prasanth Bhat, a neonatal consultant at the Royal Sussex, told the inquest James was "a very high risk transfer" because he was so unwell and could die.
The inquest heard inserting a UVC was especially difficult because premature babies are very small.
Dr Bhat said: "UVCs are notoriously bad for being misplaced, either they are too far or too near the heart.
"Getting that in an accurate position is very difficult because you can be too far in or too far below."
Brighton and Hove Coroner Veronica Hamilton-Deeley slammed hospital bosses for failing to follow strict guidelines when inserting a catheter.
"Protocols and procedures were not being carried out properly," she said.
"That is very serious."
She said the actions of doctors led directly to James’ death adding: "It’s an extraordinarily serious situation."
Recording a finding of medical misadventure, she said a UVC line may not be been appropriate given it was put in at night around 12 hours after the original decision had been taken to insert it.
She said: "The UVC was misplaced from the start and a failure to follow Trust’s guidelines resulted in the continued use of that UVC.
"This continued use over 36 hours caused James to become septic and led directly to his death."
She said there was an "ongoing failure" among clinicians to recognise errors had been made in his care.
She called for a review of Medway Hospital’s guidelines and greater vigilance from doctors and their bosses.
An inquest heard James Barnes was born at Darent Valley Hospital in Dartford, Kent on April 22.
He was born at just 32 weeks gestation and was generally healthy though he was suffering breathing difficulties.
Due to his prematurity his lungs had not properly developed and he was placed on a ventilator to help him breathe.
The following day he was transferred to the Medway Maritime Hospital in Gillingham – 15 miles away.
James was admitted to the hospital’s neonatal unit where he was treated by specialist staff.
A registrar inserted a umbilical veinous catheter (UVC) that can be used to infuse sick babies with nutrition and antibiotics.
However the inquest heard it was incorrectly placed in his abdomen before liquid was infused.
As a result his condition quickly deteriorated and a review was ordered where an x-ray showed the catheter was wrongly placed.
Dr Ghada Ramadan , a consultant paediatrician at Medway, said: "There was a line crossing the upper part of the abdomen that was veering to the left side, that looked quite odd."
Her colleague Dr Helen McElroy, a consultant paediatrician, said the junior doctors working at the neonatal unit knew the line "wasn’t quite right but it didn’t scream out to them."
The catheter was removed but when his condition worsened further they felt he may be suffering from a perforated bowel.
Despite being desperately ill the baby was a transferred 50 miles to the Royal Sussex Hospital for surgery.
James’ mother Genanne Barnes told the inquest: "We were told there was a very slim chance he would make it."
His father Michael Barnes added: "We were told there was nothing more that could be done at Medway.
"However when he arrived he was too ill to be operated on and died just hours later in April 28.
"Dr Andreas Marnersides, a pathologist, said he found haemorrhagic bleeding around the liver which could have been the result of an injury caused by the catheter."
He said: ‘This child was doing well until the UVC was introduced and then began to deteriorate very rapidly so I took the view that it was more likely because of the insertion of the UVC’."
After the inquest Mr and Mrs Barnes said it was a "relief" that it was finally over and concurred with the coroner’s findings.
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