The family of a newborn baby who died at Lincoln County Hospital after mistakes were made by medical staff have spoken of their tragic loss after a three day inquest.
Theo Robert Kuhn was born on September 2, 2014 by caesarean section and died the next morning following severe respiratory complications.
Medical professionals admitted that failures by staff to effectively monitor his condition and ultimately conduct a crucial chest drain procedure were “critical factors” in his death.
A review into Theo’s death revealed he had suffered from neonatal respiratory distress syndrome and ultimately pneumothorax, a collection of gas in the chest cavity which causes the lung to collapse.
Concluding the inquest on Thursday, February 4 at the Lincoln Cathedral Centre, Stuart Fisher, HM Senior Coroner for Lincolnshire, summarised evidence which highlighted failures by neonatal staff at the hospital to communicate and act quickly on Theo’s deteriorating condition.
He added that the doctors dealing with Theo failed to insert a chest drain, which had “serious consequences”. He described the case as “heartbreaking”.
The inquest heard in a testimony by Dr Vanessa Cox, who was the registrar on night duty between September 2 and 3, that she had been working both on the paediatric ward as well as the neonatal ward – some distance apart on the hospital site.
She had been informed of inspections on Theo’s condition by nurse Bridie Fields via phone calls while she dealt with urgent matters on Rainforest Ward, but admitted that she had not inspected Theo herself between 10.30pm on September 2 and 7.30am on September 3.
The inquest heard that blood gas test results and oxygen reliance levels were kept under close watch, but aspirations of dark fluid and worsening results signalled a potentially serious condition at around 5.20am and an inspection should have been carried out.
Coroner Stuart Fisher acknowledged Dr Cox had not visited the neonatal ward due to pressures on Rainforest Ward and had relied on an “inexperienced doctor” to relay information.
He added: “The approach lacked, in my view, a sense of urgency”.
On detection of pneumothorax staff took emergency measures but admitted no attempt had been made to insert a chest drain stating “there was no time”.
Stuart Fisher noted an admission by Dr Suresh Babu, who was also involved in Theo’s case, that he had “extensively reflected on the incident and should have inserted a chest drain before Theo was incubated.”
He had added: ” If the chest drain had been inserted there would have been a different outcome. Theo would have lived.”
Theo’s mother Laura Kuhn and her family released the following statement following the conclusion of the inquest:
“Our Theo should still be with his loving family today. He would now nearly have been one and a half years old.
“Unfortunately his life was tragically cut short at less than a day old by mistakes made at Lincoln County Hospital.
“We will never know the boy and man he would have become. His loss affected us every moment of every day.
“We hope that necessary lessons will be learnt by the hospital and that the tragic circumstances of the case are never repeated again.
“We wish to thank our friends and family for their support since the devastating loss of our Theo.
“We would also like to thank our solicitors Langleys, and our barrister, who have assisted us in this difficult but important process.”
Coroner Stuart Fisher added that the subsequent internal investigation conducted by United Lincolnshire Hospitals Trust was “ruthless, and spread the net most widely”, with staff undergoing “impressive” additional training and simulations to prevent similar occurrences in future.
Dr Suneil Kapadia, Medical Director at United Lincolnshire Hospitals Trust, said after the inquest: “I know that an apology can’t turn back the clock or help Theo family’s with the pain and grief they are suffering, but on behalf of the Trust I would like to apologise unreservedly to his family.
“The trust has carried out our own internal review into Theo’s death and we have learnt from this tragic incident to make sure this doesn’t happen again”.