Blocked breathing tube caused baby death

A THREE-DAY-OLD baby died after a registrar failed to notice his breathing tube was blocked, an inquest heard.

Tyron Firth was transferred from Barnsley to Nottingham City Hospital after being born with severe breathing difficulties at just 30 weeks.

He had hyaline membrane disease, which develops in premature babies with small lungs. A breathing tube had to be fitted and Tyron was put on a ventilator in intensive care.

But when his condition worsened in the early hours of August 3 last year, nurses repeatedly asked registrar Dr Sumita Saha to call neonatal consultant Dr Stephen Wardle for help.

But this was not done and Tyron became so ill the tube was removed so he could be resuscitated.

A post-mortem examination revealed that his death had been caused by the tube being blocked with mucus and blood. Notts coroner Dr Nigel Chapman recorded a narrative verdict and said: "Tyron died due to a blocked endotracheal tube. He was very ill but the signs were not recognised by the registrar and help was not sought."

Specialist neonatal intensive care nurse Louise Bolton, in charge of Tyron's care during the night shift, said that Tyron's condition worsened and at 11pm she asked Dr Saha to call Dr Wardle.

"I thought she had done it as she was on the phone at the nursing station," said Ms Bolton.

By midnight Tyron's condition had not changed and Miss Bolton again asked Dr Saha to call Dr Wardle. At 2am a decision was made to take the tube out to clean it.

"The baby was desaturated severely and was extremely blue – so we started cardiac resuscitations," said Ms Bolton.

"I asked Dr Saha to remove the tube. When we took the tube out it was blocked."

Dr Saha was not at the inquest because she had returned to India.

An investigation into Tyron's care was carried out by Nottingham University Hospitals Trust and Dr Wardle said that the lessons learned were now used in staff training and education.

"It is very difficult for nurses to go above a registrar to call a consultant," he said.

"But training now ensures nurses are confident to call a consultant if they feel they have to be called."

But he said it was still impossible to know if Tyron would have survived had the tube not been blocked.

It may have been that Tyron could have lived for just a few more hours.

Dr Chapman said: "He was very ill but he had a chance of survival and the team were giving him that chance."

tanya.holden@nottinghameveningpost.co.uk