Baby’s death following feeding line complication at Norfolk hospital prompts review
- Credit: Archant
A national review has been ordered into neonatal care after a premature baby died from a rare complication caused by a feeding line, which had been misdiagnosed by a Norfolk hospital.
Jackson Sellers-Mitchell was born nine weeks early on May 4 at the Queen Elizabeth Hospital in King's Lynn and was transferred to the neonatal intensive care unit (NICU) with breathing problems.
However, six days later, doctors turned off his life support at the Norfolk and Norwich University Hospital where he was transferred for specialist support.
Jackson's parents, Ricky and Zoe, of Tennyson Avenue, King's Lynn, were yesterday told that their baby had died as a result of a complication following the insertion of a feeding line on the day he was born at the QEH, which had been misdiagnosed as a gastro-intestinal condition.
The inquest in Norwich heard that a review was being conducted by the Department of Health and British Association of Perinatal Medicine into the use of umbilical venous catheters (UVC) in premature babies and how long they should be used to administer feeding solutions.
Experts added that the East of England neonatal network was changing teaching methods and raising awareness of the complication after it emerged that none of the doctors working in neonatal medicine in the region had come across a case of the rare problem.
The inquest heard that it was standard practice for NICU staff to insert a UVC into premature babies to give them the vital fluids and nutrition they need in their first few days.
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However, whilst the line inserted into Jackson, who weighed just under 4lb, was lower than best practice, it was still in an acceptable position, said Glynis Rewitzky, who treated him at the QEH.
Jackson was transferred to the N&N on the morning of May 9, but died the following day.
Norfolk Coroner Jacqueline Lake concluded that the baby had died due to a 'rare, but recognised risk of necessary medical treatment.'
She added that she would be making a report urging authorities to put measures in place to prevent a repeat of the UVC complication, but said she had no criticism of the doctors responsible for Jackson's care.
The QEH staff had thought Jackson was suffering from necrotising enterocolitis. However, N&N doctors and a post mortem examination later found that the baby had died from intraperitoneal extravasation of parential nutrition solution caused by the UVC insertion.
The inquest heard that the very concentrated feeding solution had leaked and caused haemorrhaging around Jackson's liver, which had entered his abdomen.
Susan Rubin, consultant paediatrician at the QEH, who conducted a review into Jackson's care, said the hospital was determined to learn from the tragedy.
'We need to learn from this awful incident. As a hospital we are extremely sad we did not pick up this diagnosis. However, in hindsight it is an incredibly hard diagnosis to make when it is incredibly rare,' she said.
Paul Clarke, consultant neonatologist at the N&N, added that 90pc of NICUs across the country would have accepted where Jackson's UVC had been placed. However, there was some ongoing work by researchers in Southampton about the complications caused by inserting the lines in premature babies.