A one-day-old baby died of a stroke and a birth-related head injury, an inquest heard.
Coroner Stuart Fisher made the narrative verdict at the inquest into the death of baby Oliver James Scothern who died on September 10, 2015.
Oliver’s parents, Sam Scothern and Leanne Hoy, of Grantham, heard the verdict at the inquest on Friday at the Lincoln Cathedral Centre.
The inquest also heard that on returning home after Oliver’s birth, the parents found police there ready to take their 11-month-old daughter, Amelia, away. Amelia was put into the care of family members for three weeks. Police later concluded that there was ‘no evidence of criminality’ in Oliver’s death.
Miss Hoy told the inquest said she had requested a doctor examine Oliver. Examining doctor Dr Burnhill told Miss Hoy that her son would be further examined because his sister had a hole in her heart. Miss Hoy said Oliver’s hands and feet were purple but Dr Burnhill made no mention of that. Miss Hoy described Dr Burnhill’s examination as ‘cursory’ and said that Queen’s Medical Centre later told them Oliver did have a heart murmur.
After being discharged from hospital, a midwife visited the family home and examined Oliver. She was concerned about his temperature which was low and she called Nottingham City Hospital which recommended she call an ambulance.
A paramedic arrived. He was not unduly concerned about Oliver, but an ambulance later took him to QMC where staff attempted to resuscitate him. Unfortunately, Oliver died just before 7pm.
The inquest was told that a post mortem found that Oliver has died of haemorrhagic cerebral infarction or a stroke and a birth-related head injury. It also found that there was no evidence of any ‘inflicted injury’.
Joanne Hoy, Oliver’s maternal grandmother, had told police that Oliver did not cry very much after being born and resembled a “doll”. She said he looked “really blue” and was very cold. She said, in her opinion, the care Oliver has received was “inadequate” and she thought he had been discharged prematurely.
Community midwife Jenny Moore examined Oliver at the family home at 2.30pm on September 10 and recorded Oliver’s temperature of 32.8 degrees centigrade. She gave him an additional blanket and cuddled him to try and warm him up. She called 999 at 3.05pm and about 10 minutes later paramedic Simon Nelmes arrived.
Mrs Moore, a very experienced midwife, agreed Oliver was hypothermic. She said: “I agreed Oliver was very ill. He should have been take to hospital more quickly and I should have remained with him.”
Asked why he did not take Oliver to hospital in his fast response vehicle, Mr Nelmes said it was not the policy of East Midlands Ambulance Service at the time. He said he needed back-up and he requested an ‘amber’ response as Oliver did not show signs of distress and his colour was normal. He said if he thought it was a life-threatening situation then he would have asked for a ‘red’ backup, meaning the ambulance would have used its blue lights.
Oliver arrived at QMC at 5.10pm and he was taken from A&E to the resuscitation department. The inquest heard that at this stage Oliver was “pale and cold” and his heart was only beating between 80 and 100 beats per minute when it should have been about 150 beats per minute.
Professor John Wyatt, an expert witness, had told the inquest that Oliver’s head circumference was bigger than his body weight which may have contributed to the injury he sustained during birth. Professor Wyatt said that up to 50 per cent of babies suffer a bleed on the brain during normal birth and one in 5,000 can suffer permanent damage during the natural process of passing through the birth canal.
Prof Wyatt said he believed that Oliver suffered a traumatic brain injury which later led to a “cascade of damaging physiological processes.” He added: “In my opinion this cascade of damaging processes together with the direct consequences of the brain infarction led ultimately to Oliver’s cardio-respiratory arrest. It seems clear that neither the community midwife nor the paramedic who attended the home from 3.10pm on September 10 recognised the ominous significance of Oliver’s marked hypothermia. The situation was clearly highly unusual in that it appears apart from the low body temperature and the difficulty in detecting a pulse there appear to have been no other abnormal clinical signs to indicate that Oliver was seriously ill.”
Prof Wyatt also said he did not think that the situation would have been any different if Oliver had been taken to hospital 30 minutes earlier. He said if Oliver had survived he probably would have suffered a permanent brain injury leading to cerebral palsy, seizures and learning difficulties.