Archie Haxell · Prevention of Future Deaths report

On 10 April 2013 I commenced an investigation into the death of Archie Haxell, age 5 days. The investigation concluded at the end of the inquest on 27 February 2015. The conclusion of the inquest was that the medical cause of death was extensive brain haemorrhage and hypoxic ischaemic encephalopathy. The narrative verdict was as follows:

About 2 hours after his birth at Queen Elizabeth Hospital, Archie Haxell suffered a respiratory arrest. He was found to have had extensive brain haemorrhage and hypoxic ischaemic encephalopathy although the underlying cause of these remains unknown. He was transferred to St Thomas’ Hospital where he died on 29 March 2013. Breakdowns in communication between healthcare professionals and with Archie’s parents contributed to the delay in recognising Archie’s deteriorating condition.

The circumstances are also set out in the Trust’s serious incident investigation report dated 12 August 2013. Briefly, Archie was the eldest of twins and was born in seemingly good condition in theatre by forceps delivery on 24 March 2013. About 2 hours after his birth Archie suffered a respiratory arrest. He was transferred to SCBU and then to St Thomas’ where he died at the age of 5 days.

(1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was ████████ performed a set of observations, including oxygen saturations and she also noticed vomiting, grunting and nasal flaring. The evidence at the inquest was that the observations on a piece of paper because the medical records were not immediately available (her observations were performed shortly after the birth of Archie’s brother who required resuscitation). Midwife ████████ later transcribed these results into the medical records. However, the evidence was that midwife ████████ was not aware of the vomiting, grunting and nasal flaring noticed by midwife ████████ although midwife ████████ believes she did pass this information on verbally.

During this period may understandably have been focussed on Archie’s brother. However, I am concerned that the important information about further possible signs of respiratory distress was somehow lost in the communication between the two midwives.

Also, the piece of paper on which the observations were recorded was not retained. I am concerned that this should have been retained in the medical records.

(2) No-one informed Archie’s parents of the concerns about Archie’s breathing. After returning to delivery suite ████████ was left alone with Archie for a period of between 7 and 10 minutes. During this period ████████ noted that Archie’s breathing was irregular. My finding at the inquest was that if he had known of the midwives’ concerns he would have raised the alarm sooner, although it was not possible to say from the evidence whether this would have altered the outcome.

I do of course understand that a balance needs to be maintained between sharing relevant information with parents and causing unnecessary alarm. However sharing relevant information potentially enables parents to make important contributions to their child’s care and my concern is that this opportunity was lost in this case.