Inquest Into Death Of Newcastle Baby
8 March 2018, 12:00
A series of failings by a locum surgeon directly contributed to the death of a two-day-old baby, a coroner has ruled.
Baby Paul Mitchelhill died in his mother's arms following abdominal surgery at the Great North Children's Hospital in Newcastle in October 2013.
An inquest heard opportunities to save his life were missed in the hours after the operation went wrong.
Locum Emmanuel Towuaghanste - known as Mr Towu - opted to repair the birth defect in a single operation.
The condition is known as an exomphalos major and it meant some of Paul's stomach and liver were covered in a membrane and protruding.
The inquest at Newcastle Civic Centre has heard Paul was in a stable condition and other expert surgeons told the four-day hearing that they would not have operated immediately.
Mr Towu, 62, did not consult with the baby's parents - Paul and Irene - before the operation and delegated gaining their consent to his registrar, and so had no discussed their treatment options.
Nor did Mr Towu consult with permanent colleagues before the 3.30pm operation.
Coroner Karen Dilks said Mr Towu did not share the concerns expressed by colleagues that Paul's abdomen was tight and that his legs were "dusky" after the operation.
The baby, who was born prematurely in Carlisle, developed Abdominal Compartment Syndrome, a recognised and serious complication which led to major organ failure.
Mr Towu was contacted by a colleague more than six hours after the operation and was urged to review the tiny patient.
At midnight and 3am, Mr Towu saw Paul and decided he needed more fluid, rather than to have his stomach reopened to relieve the pressure.
It was not until 7am the day after the operation that Mr Towu elected to reopen Paul's stomach, by which time it was too late to save him and he died at 8pm.
Mrs Dilks said the independent expert surgeons had given evidence to say Paul was likely to have been saved had his stomach been opened up before midnight, and still had a chance of living had it been done before 3am.
They told the coroner the standard of care he received fell below what was reasonable, she said.
At the conclusion of a lengthy narrative verdict, she said: "These failings directly contributed to Paul's death."
Mr Towu gave evidence at the inquest but was not in court for the conclusion.
The coroner said she will pass on her findings to the General Medical Council.
Speaking to the baby's parents, the coroner said: "I would like to extend to you both my very sincere personal condolences on the tragic loss of your son."
Newcastle upon Tyne Hospitals NHS Foundation Trust said: "Newcastle Hospitals very much regrets this tragic death.
"This arose out of the refusal of a locum surgeon to respond to the professional concerns of various committed expert and experienced medical, surgical and nursing staff."