Warsop baby died hours after birth from rare heart defect following breakdown in communication from hospitals
A Church Warsop baby died hours after his birth because doctors were not made aware of the severity of his heart condition, an inquest has been told.
Kit Aaron Callanan died at Chesterfield Royal Hospital on January 15 last year – two days after his mother had been due to be induced by specialist doctors in Leeds, Chesterfield Coroners’ Court heard on Thursday.
He had been diagnosed with transposition of the main arteries leading from his heart – meaning they were the wrong way round – months before he was due to be born, and would have needed emergency surgery shortly afterwards.
But when his mother went into labour naturally and attended her nearest hospital – as she had been advised by medics – Chesterfield Royal did not have cardiac neonatal cots on site and was not equipped to save his life.
In his care plan, it had been arranged that his mother would be induced at Leeds at 38 weeks to give the infant the best chance of survival.
The family had been advised that if they needed emergency attention to attend their nearest hospital, because it was deemed better to get the mother and child into a clinical environment where they could then be transferred to an appropriate specialist care centre elsewhere in the region.
There was greater risk, the inquest heard, of the mother remaining at home or going into labour as she travelled to Leeds.
But when the family arrived at Chesterfield Royal, her notes had not been updated by staff in Leeds and medics were left unaware that the child’s heart condition was so severe or that the planned induction had not taken place days earlier, the inquest heard.
Consultant obstetrician, Dr Andrew Breeze, from Leeds Teaching Hospitals NHS Trust, said the plan had been to allow Kit’s mother to give birth naturally following the induction – as she’d had four previous pregnancies – before moving him immediately to a specialist cardigan neonatal unit.
He said that, due to a regular shortage of cots on such units, it was not uncommon for inductions to be postponed ‘as a delay of a couple of days presented little risk to mother or baby’.
Kit’s mother had expressed concern that she was not due a visit from a midwife that week – as she had been due to give birth and would have been in hospital, the inquest heard.
Arrangements were then made for a phone consultation with an outreach team, but this never happened, and when the family arrived at the Chesterfield hospital, the baby’s mother was already in labour.
Dr Elspeth Brown, consultant paediatric and fetal cardiologist at Leeds Teaching Hospitals, said problems had been detected with Kit’s heart at 20 weeks.
She said: “He would have had much more chance of survival if he had been born in Leeds but I can’t say definitely that he would have.”
The inquest, which was opened in July 2020, had already ruled that Kit’s cause of death had been congenital transposition of the great artery.
Dr Nour Alshurbasi, consultant paediatrician at Chesterfield Royal, told the inquest: “In the ideal circumstances, we would have avoided a situation where the mother went into labour naturally.”
The inquest continues tomorrow (Friday).