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"Serious failings" in care of newborn baby.


A newborn baby was left gasping for breath as he lay dying alone on a resuscitation table after an error by doctors who declared him dead too early.

Sebastian Sparrow revived himself an hour and a half after his parents were told he had died, an inquest at St Pancras Coroner's Court was told.

By the time doctors realised the baby was still alive, he was too badly brain damaged to be saved, and died two days later, coroner, Mary Hassell, heard.

Sebastian was born by Caesarean section on November 6, 2013 at the Royal Free Hospital, Hampstead, North London, after his mother, Sally Sparrow, endured a long labour.

In a statement, Mrs Sparrow, a solicitor, and her husband, Jamie, an accountant, said they were left with "no real understanding of what had happened" after the mistaken diagnosis of death.

Sebastian, Mrs Sparrow's first baby, was full-term when she went into labour and was admitted to the Royal Free.

He was born "in a very poor condition" which shocked the delivery team because no complications were detected before birth. It took three tries by different obstetricians to deliver him by Caesarian section, which may have caused brain damage.

Sebastian was delivered "pale, floppy and with absolutely no tone", according to medical staff, and was not breathing.

He was rushed to the operating theatre where a special unit battled to save Sebastian for 30 minutes before death was apparently pronounced - although doctors failed to call a time of death.

The baby was left on the resuscitation table and medical staff offered condolences to his traumatised parents as his exhausted mother lay on the operating table recovering from her Caesarean.

Midwives went to dress and prepare baby Sebastian to be held by his parents, who were taken to a private room to wait for him.

But 30 minutes later they were told by a paediatrician that the baby was making "post-death gasping actions" which were distressing even for medical staff to witness and the Sparrows were asked if they preferred to wait for this to pass before holding him.

Mr and Mrs Sparrow said in their statement: "Thinking that Sebastian was dead, and not wanting to make our distressing situation even worse, we chose to wait.

"Another hour passed, before the paediatrician returned to tell us that he didn't understand what had happened, that neither he nor the other hospital staff had seen anything like it, but Sebastian had revived himself and was breathing unaided and had a regular heartbeat."

But the paediatrician told them that, because 90 minutes had passed since Sebastian was thought to be dead, he hadn't had any oxygen and his vital organs may have been damaged.

The critically-ill baby was rushed to a specialist neo-natal unit at University College Hospital where he was given a new treatment, xenon gas, but his parents were told that he had severe brain damage and nothing more could be done.

Mr and Mrs Sparrow said: "On November 8, treatment was withdrawn, and nature took its course." Sebastian died in his mother’s arms shortly afterwards.

Giving evidence, a neo-natal specialist at UCH, Dr Janet Rennie, said she believed Sebastian's brain injury was probably caused by delivery attempts during the Caesarean.

She said the mistaken diagnosis of death had lead to further complications, such as organ failure and immune system shutdown.

When Sebastian died, Dr Rennie told the Sparrows that the cause of death had already been ascertained.                                     

The shattered couple said: "On that basis we decided not to have a post-mortem, but to let Sebastian rest after such a short, traumatic life."

And doctors crucially failed to report Sebastian's death to the coroner, which Ms Hassell said was a clear breach of medical duty.

A post-mortem examination was not performed.

The most senior consultant paediatrician who tried to save Sebastian at the Royal Free, Dr Rahul Chodhari, said he "cannot remember" why it was decided not to call the coroner, when they mistakenly believed the baby had died.

Quizzed by Ms Hassell, he admitted that he recognised there were "signs of life" in Sebastian 30 minutes after resuscitation attempts were stopped but he chose not to reactivate resuscitation because he thought the likely outcome would be death or serious brain damage.

He said he now accepts "wholeheartedly" that there were serious failings in Sebastian's care and that he would do things differently in future.

After their initial shock, the Sparrows were left with more questions than answers and their fight for the truth led to an inquest after a two and a half year wait.

Coroner Mary Hassell said medics must have realised the infant's "agonal gasps" meant that he was "dying, and not dead.”

Responding to the narrative verdict, Sebastian’s parents said: “Following the unimaginable trauma of these events, one of the most worrying ongoing aspects for us has been the NHS’s wholly inadequate investigation into what may have happened.

“The Trust’s Serious Incident Report even to comment on the fact that the hospital misdiagnosed Sebastian’s death. Nor did it even consider the possibility that the trauma to Sebastian’s head was as a result of the multiple failed attempts of junior obstetricians to deliver his head.

“This failure to establish the facts makes it impossible for the NHS to identify possible errors and therefore learn from them, putting lives at unnecessary risk. It means that families like ourselves must spend years trying to establish the facts of what happened to their loved ones, reliving the worst moments of our lives, time and time again.

“This reluctance to properly investigate and report has to stop – the culture must change – they must learn from their mistakes and cannot keep burying their heads in the sand.”