Cassian Curry inquest: Sheffield Hospital ‘negligence’ contributed to death of two-day-old premature baby UK News

Cassian Curry was born in the Jessop Wing maternity ward at Sheffield University Hospitals on April 3 last year, aged 28 weeks and ‘very small even for her age’ at 1lb 10oz (750g).

A Sheffield Coroner’s Court inquest heard how Cassian deteriorated rapidly on April 5 and died of cardiac tamponade, which is when fluid builds up in the space around the heart, ultimately preventing him from pumping.

On Friday, Deputy Coroner Abigail Combes concluded that a failure to record and share information about Cassian’s care contributed to his death.

The hearing was told this week that an umbilical venous catheter inserted into Cassian’s abdomen to help him feed was in a ‘suboptimal’ position near his heart when inserted by two young doctors.

Neonatal consultant Dr Elizabeth Pilling told the inquest she intended to have him repositioned within 24 hours but had waited because of the dangers of repeatedly handling such a premature baby than Cassian.

Dr Pilling said she had no explanation as to why she then forgot to make sure her feeding line had been moved.

Giving her conclusion, Ms Combes said the decision to suspend the proceedings and reassess them within 24 hours was “reasonable and appropriate”, but was “not properly recorded and communicated” in Cassian’s notes, or during the tour of the service.

The plan should have been recorded on Cassian’s “pink sheet”, she said, and communicated to her parents.

Ms Combes said it amounted to a “gross failure” in Cassian’s care, which contributed to his death.

She added: “If not for this incident, Cassian would not have died what he died of, when he died.”

The coroner recorded a narrative finding, that Cassian’s death was “contributed to negligence”.

In a statement at the start of the hearing, Cassian’s mother, Karolina Curry, said she and her husband James had a number of questions about her son’s treatment, including reports that the unit was missing. of staff due to the Easter weekend.

But Ms Combes concluded: ‘There were no systemic failures in the form of personnel issues that caused or contributed to Cassian’s death.

She said manning levels were above national requirements this weekend, and while there were a number of junior personnel in attendance, they were “appropriate and able to adequately support the unit”.

Sheffield Teaching Hospitals NHS Foundation Trust medical director Dr Jennifer Hill said the trust was ‘truly sorry about what happened’ to Cassian, admitting there was ‘human error in the management of the venous catheter Cassian’s umbilical”.

Following the inquest, Dr Hill said there had been a full review, changes had already been made and he would consider any further recommendations from the coroner.