Parents feel ‘let down’ by Ipswich Hospital after coroner highlights failings but rules out neglect
PUBLISHED: 18:07 17 April 2019 | UPDATED: 18:12 17 April 2019
The bereaved parents of a three-day-old baby feel “totally let down’” by Ipswich Hospital despite a coroner ruling that numerous failings had not amounted to neglect.
Lilly Mae Tamasi died at Addenbrooke's Hospital as a result of a brain injury caused by an intracranial bleed.
Parents Georgina and Zoltan Tamasi, of Trimley St Mary, had visited Ipswich Hospital on September 11, 2017, after Georgina experienced contractions and reduced fetal movement.
When Lilly Mae's heart rate was found to be low, a decision was made to conduct an emergency caesarean section.
Obstetrician Dr Saadia Farrakhm, who carried out the six-minute procedure, said Lilly Mae was “floppy” and had “no tone in her body”.
Questions were raised during an inquest over whether or not Lilly Mae, who weighed 2kg (4lbs) when born, could have suffered an injury to her head during birth.
Coroner Nigel Parsley said that although the pathologist could not it rule out, there was no evidence to suggest birth trauma led to a subcutaneous haemorrhage he ruled to be the cause of death.
A consultant neonatologist believed Lilly Mae's lack of tone may have hampered delivery, but did not believe she suffered any head trauma during birth.
Lilly Mae was transferred to the neonatal intensive care unit, but returned to the ward with her parents when her condition picked up. However, she later became unwell, turning “grey and unresponsive” .
After suffering seizures, she was rushed to Addenbrooke's, where she died on September 14.
Questions were raised by the family's representatives about whether she should have stayed longer in the neo-natal unit.
A Serious Incident Requiring Investigation report following the death described earlier assessments from a midwife as “inadequate” and highlighted nine points for attention, including lack of prompts in the telephone triage tool, record keeping in the first hour of care and first admission, and work load and staffing escalation.
“The hospital has identified failure to adhere to correct procedures and policies,” said Mr Parsley, returning a narrative verdict.
“Although the issues raised are rightly cause for concern, it's not clear any combination of decisions had a direct causal link on Lilly Mae's death.
“At some point during labour, at birth, or just after birth, Lilly Mae suffered an intracranial haemorrhage leading to a severe hypoxic brain injury, but the cause couldn't be ascertained on the basis of available evidence.”
Lilly Mae's parents said they remained devastated at the loss of their daughter, but angered by “inconsistencies” in the evidence of NHS Trust staff during the inquest into her death.
“We feel totally let down by the care we received and believe this led to the death of Lily Mae.”
Solicitor Lynda Reynolds, of Hugh James, said legal representation had been imperative to get to the bottom of what happened.
Jan Ingle, head of communications at Ipswich Hospital, said: “This was a complex medical case with the coroner finding that Lilly Mae suffered from a very rare intracranial bleed leading to hypoxic ischaemia. The cause of the bleed could not be determined.
“The Trust has carried out a thorough investigation into the circumstances of Lilly Mae's death and has cooperated fully with the inquest process.
“The Trust wishes to offer its sincere condolences to Lilly Mae's parents and family.”
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