Baby died after doctors read X-ray wrong and left catheter in wrong place
Published 17/12/2015 | 17:30
A newborn baby died after doctors made a mistake reading an X-ray and left a catheter in the wrong place, a coroner has ruled
Assistant Avon Coroner Robert Sowersby said the errors in Abigail Goodall's care were not spotted because neonatal specialists in Bristol were over-reliant on echocardiograms.
The four-day-old baby deteriorated so rapidly that the staff treating her at St Michael's Hospital were unable to save her.
Avon Coroner's Court heard two catheters - one to a vein and the other to an artery - were inserted into Abigail's heart by an F2 junior doctor shortly after she was born.
The venous line was used to give nutritional fluids while the arterial line was for checking blood pressure and taking blood samples.
An X-ray was taken to check the position of the two very-similar looking catheters, which were overlapping, and senior doctors felt the venous line was in the wrong position and moved it a couple of centimetres.
But they instead repositioned the arterial line - leaving the venous catheter in its original place - sending the total parenteral nutrition (TPN) fluid into the right atrium.
The inquest heard that several neonatologists thought that if the catheters were in the wrong place the cardiologists reviewing Abigail's echocardiograms would spot the mistake.
A leading pathologist at Great Ormond Street Hospital found that Abigail, who had been born with a congenital heart defect, had suffered a fatal pericardial effusion from the build-up of fluid around the organ - a rare but recognised side effect of TPN treatment.
However, doctors at St Michael's Hospital suggested instead that Abigail's sudden deterioration and death on October 28 last year was consistent with an E.coli infection.
She was delivered by caesarean section at 5.33am on October 24 last year and taken immediately to the intensive care unit and later placed on a ventilator. At 4am on October 28 she took a turn for the worse and died a short time later.
Pathologist Dr Michael Ashworth gave Abigail's cause of death as a pericardial effusion with tamponade, treatment with TPN, a complex congenital heart disease and DiGeorge Syndrome.
He said that although E.coli was present at post-mortem it was not a "significant contributor".
The coroner recorded a narrative conclusion and said he would write a report highlighting the limitations of echocardiograms.
"The tip of the catheter was in Abigail's right atrium and should not have been located where it was but it had been inserted at the same time as an umbilical arterial catheter," he said.
"When X-rays were performed to confirm the position of these two lines one catheter was mistaken for the other and subsequent reviews of the cardiology did not detect the problem.
"I accept that clinical errors were made in terms of the line placement but having reviewed the records and spoken to the doctors it seems to me that in general terms her standard of care was good."
Referring to the Regulation 28 report, Mr Sowersby said: "One area I am considering making a report about is the clinicians' expectation of what an echocardiogram will show because it seems to me that quite a number of the neonatal clinicians have been under the apprehension that an echocardiogram will show them all sorts of things that in fact it won't show.
"I am not critical of the neonatologists when I say that but it is quite worrying if they are thinking that if there is a problem the echocardiography will pick it up and the consultant will tell us if it fact it won't pick it up.
"Part of the purpose of these reports is that they are circulated and they identify broader learning points. It is quite possible that this is not the only trust where there is this misunderstanding."
Abigail's parents, Andrew and Sarah Goodall, from Trowbridge, Wiltshire, attended the two-day hearing supported by family.
Mrs Goodall said afterwards: "Sitting through this inquest and listening to the evidence of failings in Abigail's care has been so difficult for us.
"It is devastating to lose a child but to learn later that our daughter's death could have been avoided is utterly heart-breaking.
"Nothing will bring Abigail back, but we hope that highlighting the errors in our case will lead to improvements which mean no other family has to suffer like we have."
The family's lawyer Nisha Sharma, from Slater and Gordon, said: "This is a deeply worrying case.
"Mr and Mrs Goodall are determined that some positive comes from this tragedy and that any failings identified in baby Abigail's case are put right so no other family has to go through a similar trauma."
Dr Bryony Strachan, clinical chairwoman of the division of women's and children's services at University Hospitals Bristol NHS Foundation Trust, said: "Our condolences and thoughts are with Abigail's parents and grandparents at this very difficult time.
"Abigail was born with a very complex congenital heart disease as a result of a genetic condition
"While treating her, doctors inadvertently positioned wrongly lines which were a necessary part of Abigail's care.
"When we knew the error had occurred, we met with Abigail's family, investigated fully and are taking steps to reduce the likelihood of a similar error occurring again.
"We hope this will be some comfort to Abigail's family and would like to again apologise unreservedly to them."