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Investigation and inquest
On 25/04/2018 I commenced an investigation into the death of Kiarah Faith Adora Allen. The investigation concluded at the end of an inquest on 20th August 2018. The conclusion of the inquest was: Kiarah died from an inadvertent fluid overload of TPN given via an UVC as a result of unsafe staffing levels, not correctly following procedure and failing to learn from a previous similar event. Her death was contributed to by neglect.
Circumstances of the death
Kiarah was born at 25 plus 5 weeks gestation on 09/02/18 at 20.00. She was admitted to the neonatal unit where she required medical support including Total Parenteral Nutrition (TPN) with starter vamin. On 10/02/18 at around 11.20 her TPN needed changing to Neo 12. At the time two junior sisters were involved. During the course of the change one junior sister was called away to another baby. During the change both types of TPN were inadvertently left attached to the baby via the umbilical venous catheter (UVC). The start-up Vamin continued to go through the pump however the Neo 12 was attached directly to the UVC. When the clamp to the UVC was removed the Neo 12 infused direct into Kiarah leading to fluid overload of 209mls. This caused her to collapse about an hour later requiring resuscitation. The fluid overload lead to severe metabolic complications. She sadly died at 00.55 on 11/02/18. The root cause of this error was a combination of unsafe staffing numbers, a failure to follow correct procedure when changing the TPN and failure to learn from a previous similar incident.
Following a post mortem, the medical cause of death was determined to be:
1a CONGESTIVE CARDIAC FAILURE
1b ACCIDENTAL TOTAL PARENTERAL NUTRITION FLUID OVERLOAD
1c VERY PRETERM (25/40), CONGENITAL BILATERAL BRONCHOPNEUMONIA, HYPOXIC-ISCHAEMIC BRAIN INJURY AND INTRAVENTRICULAR HAEMORRHAGE
Coroner’s concerns
1. I heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff. The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there were insufficient numbers of nurses and doctors. Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for.
Information checked against the published report and official responses