Advising with empathy and experience

GP criticised by Coroner in baby death case.

A NEWBORN baby died days after his breathing difficulties were dismissed by his family's doctor who jotted down their concerns on a piece of paper and then lost it, an inquest heard.

Three-week-old Mason Kane had been taken to Duke Street Surgery, Barrow, after his parents found him short of breath with sticky eyes and a rash on his bottom.

But GP Dr Nandini Das gave Mason the all clear and said his sticky eyes should be treated with shampoo.

As the baby wasn't yet registered at the clinic, Dr Das hand-wrote details of the visit on a sheet of paper but failed to input the notes onto a computer database. She subsequently misplaced the note.

Five days later Mason was rushed to Furness General Hospital after he stopped breathing and his face turned blue at the family’s Barrow home.

He died later in hospital from multiple organ failure with tests showing he had a blood clot on his lung. He was also found to have acute pneumonia but a pathologist believed being on a ventilator caused this.

Mason’s father Robert Kane was so heartbroken at his son's death, he killed himself on his 36th birthday.

At a Manchester inquest, a coroner criticised Dr Das, who still works at Duke Street Surgery, but said there was no way of knowing whether Mason Kane’s symptoms during the consultation were linked to his death.

The inquest heard that Mason had been born two weeks prematurely in June 2014 by caesarean and was in hospital for three days before being allowed home.

Miss Sandra Charles, 45, who had been engaged to Mason's father said: ''There was some concern about him sneezing but nurses said he was fine.

"He was feeding quite well and getting into a regular pattern and he was visited by a midwife. On June 24th I saw Dr Das because Mason had a sticky eye, a rash on his bottom and was inhaling breath very noticeably.

"She checked him over and told me to put shampoo in his eye to help with the problem but I asked for a prescription instead. She didn't examine his bottom and listened to his chest but told me it was all clear and dismissed my concerns. I left the surgery feeling angry.

"Mason wasn't taking his bottle and seemed agitated, pesky and pale. The following morning I gave him a cuddle and his bottle and put him in his Moses basket. Then I heard a strange gurgling noise and his lips were blue.”

Mason was taken to Furness General Hospital, then transferred to Royal Manchester Children's Hospital where he died on June 29, 2014.

Dr Das told the inquest her surgery had since ensured records taken from unregistered patients are put into its computer system.

She said: "As a newborn baby, Mason was not registered so I made a hand written note of the appointment. However, this somehow got lost before I could put it into the system. I remember that he was bought in with sticky eyes and I advised what should be done. This did not concern me as I have seen this kind of symptom before.

"I took a swab and sent it off for analysis and it was clear. I then made a new medical record on July 8 knowing that Mason had died, but at this point I did not remember everything from the consultation.

"I don't recall the mother mentioning the breathing or problems with the bottom. I know that I would have observed the breathing and I remember that the baby was awake and alert and didn't have any trouble taking the swab.

"If I had any concerns about the baby's breathing I would have referred him to hospital and I would not have let him leave the surgery."

But recording a narrative conclusion, coroner Nigel Meadows said: "I prefer the account of Miss Charles. If Dr Das had a contemporaneous record that would be persuasive but she didn't.

"It was only on July 8 that Dr Das became aware of the death of Mason and that there wasn't a record. The General Medical Counsel states that doctors must make a reliable and contemporaneous note of consultations.

"No definitive reason can be ascertained for what happened to Mason. He had pneumonia, which can develop very quickly and, on his arrival at hospital, there was no evidence of any infectious illness."

At another inquest, a verdict of drug-related death was recorded on Mason's father who took a fatal drink and drugs cocktail of Sambuca, rum and vodka, along with diazepam and a prescription drug for epilepsy at the family home on Februrary 14 2016. The hearing was told he had been struggling to deal with the loss of his son.