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Investigation and inquest
On 27th July 2013 I commenced an investigation into the death of Isabella Hope HILL, Aged 7 days. The investigation concluded at the end of the inquest on 11th October 2013.
The conclusion of the inquest was
Ia Heart Failure
Ib Arrhythmia
Ic Ischaemic/Hypoxic Damage to the Myocardium
II Hepatic Necrosis due to leakage of TPN Fluid from an Umbilical Venous Catheter
Severe Immaturity of Lung. Necrotising Enterocolitis
Narrative Conclusion, as follows:
Isabella Hope Hill was born prematurely at 26 weeks gestation. She was stable on Continuous Positive Airway Pressure (CPAP) support. She deteriorated but initially responded well.
She underwent a Central Venous Catheterisation using an Umbilical Venous Catheter which is used to deliver intravenous fluids, nutrition, blood products and medications to sick preterm infants. Initially, it was not appreciated that the umbilical line had migrated out of a blood vessel and Total Parenteral Nutrition (TPN) fluid entered her abdomen leading to a build up of pressure on her lungs.
She suffered a circulatory collapse requiring cardiac pulmonary resuscitation. This collapse caused damage to her heart muscle leading to ischaemic/ hypoxic degenerative change and significantly disturbed the delivery of oxygen to her body tissues.
Her abdomen was noted to be tight and distended. The TPN fluid was aspirated resulting in some improvement.
She later deteriorated further and after a period of heart rhythm disturbances and cardiac arrest probably due to the cardiac injury she died at approximately 9.40 am hours on 17th July 2013
Circumstances of the death
See the Narrative Conclusion recorded in Box 3 above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
During the Inquiry, the Trust provided me with a draft Serious Incident Report that had been prepared to enable the Trust to investigate this incident and to identify what, if anything can be learned from Isabella's death and what if anything can be done to avoid the possibility of a similar incident happening again.
I emphasise that I acknowledge the report is a draft document, prepared as it was prior to receipt of the post mortem report and was intended to reflect preliminary findings which may require revision following the determination of the cause of death at inquest.
As can be seen from the above Narrative, the facts of this case involved the use of Central Venous Catheterisation using an Umbilical Venous Catheter [UVC]. Whilst there can be complications of UVC insertion including mal-positioning and line migration, an x-ray is required to confirm clinically the position of a UVC [which can commonly be mal-positioned despite use of optimal operation technique].
The evidence heard confirmed the Trust's own guidelines were not followed in this case in that such an x-ray was not performed at a point during Isabella's treatment when it ought to have been, and the Trust's review confirms that this not being done amounted to sub-optimal standard.
The Trust's document recommends a review of the UVC guidelines including a literature search of the UVC guidelines and discussions with senior colleagues at the other units in the practise, and of education and training around UVC guidelines.
Having concluded this inquest, and whilst I acknowledge that the Trust have indicated that changes have already been instigated, I now write to the Trust to confirm that in my view the Trust should take action because issues surrounding the UVC guidelines – particularly in the absence of any national guidelines – gives rise to a concern of deaths in the future.
I would therefore be obliged if the Trust would write to me in due course to confirm the outcome of their review once completed, setting out what is proposed in terms of changes to be made, and to explain what steps the Trust proposes to take to encourage medical staff to follow the guidelines. Perhaps the Trust would send me a copy of the full review document for my consideration once completed.
