Group concludes babies died due to natural causes or errors in medical care, saying there was no evidence of deliberate harm
A distinguished panel of paediatric specialists and neonatologists was convened by Dr Shoo Lee, professor emeritus at the University of Toronto, to review the medical evidence used to convictThe panel members, who rank among the most senior experts in the world, include Neena Modi, a professor of neonatal medicine at Imperial College London; Mikael Norman, a senior physician at the Karolinska Institute and founder of the International Society of Evidence-based Neonatology; and Ann Stark,...
The panel concluded that baby four had died from systemic sepsis, pneumonia and disseminated intravascular coagulation, where blood clots form throughout the circulatory system. The mother should have received antibiotics in pregnancy, the panel said. When the child was born there was a delay in recognising that she was in respiratory distress and in starting antibiotics and further treatment. There was no evidence of air embolism.
On reviewing her medical notes, the panel concluded that her vomiting was due to an infection, possibly enterovirus. They found no evidence to suggest air was injected into the stomach or that the child was overfed.The court was told that the baby girl had died after having air injected into her stomach via a nasogastric tube, leading to recurrent swelling of the abdomen, diaphragmatic “splinting”, which impairs movement of the diaphragm in breathing, and respiratory arrest.
The panel found no evidence that the endotracheal tube had been dislodged. The reason the girl’s condition deteriorated was that the tube used was too small. The initial placing of the tube was “traumatic and poorly supervised” the report claims. It adds that the consultant did not understand the basics of resuscitation, air leaks, mechanical ventilation, and how equipment commonly used on the unit worked. There was also evidence that the incubator alarms were not turned off.
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