Christ Morrison · Prevention of Future Deaths report

An investigation was opened into this death. Following an autopsy, which found that death was due to hypoxic ischaemic encephalopathy due to failure to resite a tracheostomy tube, an inquest was opened. A pre-inquest review was held and submissions obtained from a large number of potential interested persons, before the scope could be refined. It was adjourned part-heard for further evidence on 25th August 2015.

At inquest on 19th February 2016, a narrative conclusion was recorded:

Baby Christ Morrison was born at 24 weeks gestation by fast spontaneous delivery on 20th May 2005. He was initially thought to be stillborn, and was therefore not attended by staff, but was found later to have a pulse and chest movements and was resuscitated and taken to ITU. He was disabled by a degree of brain injury. His first capillary gas and his response to resuscitation make it unlikely that the period of non attendance contributed to his brain injury. Without placental pathology it is not possible to know whether his mother's bleeding was an abruptio placenta, but it is possible that this contributed to his brain injury. The principal cause was extreme prematurity, which caused some chronic lung disease and the need for a tracheostomy. He developed subglottic stenosis, some months later, which was not congenital, but caused by prolonged tracheostomy intubation. He had some tracheal reconstruction surgery. The tube was changed uneventfully on many occasions, but at about 5pm on 10th September 2014, the tube was removed by a nurse, accompanied by his guardian, and he became agitated. Attempts to replace the tube failed and emergency services were called. Despite basic life support from the nurse and advanced life support from the ambulance crews, and transfer to a specialist centre, he did not regain consciousness and died at 07.00 hours on 17.10.2014 at St Thomas Hospital.

It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence.

It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case.

Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence.