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Investigation and inquest
On 15th February 2013 I commenced an investigation into the death of Scarlett Lucie SINCLAIR, Aged 25 days. The investigation concluded at the end of the inquest on 31st January 2014. The conclusion of the inquest was
Ia Fulminant necrotising enterocolitis
II Hypoxic ischaemic encephalopathy and chronic lung disease
and history of Twin to Twin transfusion
CONCLUSION: Natural Causes
Circumstances of the death
Scarlett was born at 28 weeks gestation she one of twin girls who were both initially managed in Oxford.
The plan was to transfer Scarlett to Bristol as this was nearer to her home and I am told that this is standard practice. She was therefore transferred to the neonatal unit at Southmead Hospital at the age of 23 days on 6th February.
Within hours of being transferred she became unwell. I was told that around 3-4 a.m. she became more pale and her abdomen was distended. Medical management was commenced with a view to treating necrotising enterocolitis, again I was told during the inquest that this was standard management and an x-ray was taken.
At 7am there was an acute deterioration with necrotising surgical involvement and Scarlett was transferred for surgical management to another hospital close by. Sadly the surgeon confirmed that there was nothing that could be done due to the extent of the necrosis and Scarlett died a few hours later.
Coroner’s concerns
During the inquest evidence was given from the Consultant Locum Neonatologist at Oxford as to how a baby is assessed as being suitable for transfer to another neonatal unit. I also heard evidence from a Consultant Neonatologist from Bristol who confirmed that the assessment of suitability for transfer from the United Hospitals Bristol NHS Foundation Trust means that a baby is not transferred to another neonatal unit until they are in a much more stable condition.
I would therefore ask that you review your policy for assessing a babies wellness, stability and indeed suitability prior to approving that baby fit for transfer between neonatal units
Information checked against the published report and official responses