The inquest into the death of Baby JP concluded on 12th May 2022 at Accrington Town Hall. The case was heard before HM Area Coroner Mr Taylor.
Baby JP was born in July 2016 with a significant heart defect, resulting in him having to have a heart operation shortly after birth and remain in Alder Hey Hospital for the first 3 months of his life. A further operation was expected when baby JP turned 6 months old. Due to his heart condition, baby JP only had one pumping chamber in his heart.
Baby JP presented at the Royal Blackburn Hospital on 15th December 2016 with bronchiolitis. He was placed on a CPAP machine, providing pressurised oxygen to assist his breathing.
On 17th December 2016, a bank nurse took over baby JP’s care whilst the nurse on duty went on her lunch break. This bank nurse did not have any relevant training in respect of nursing a child on a CPAP machine.
Baby JP’s mum alerted the bank nurse to the fact that no liquid appeared to be remaining within the machine, given that no condensation was visible. An attempt was made to refill the humidifier and the machine began to alarm and consequently cut out.
Due to this, baby JP was without oxygen for some 3 – 5 minutes. Despite subsequent intubation and resuscitation attempts, baby JP sadly died.
The Coroner returned a narrative conclusion, stating that baby JP died from complications of his heart condition. The Coroner found that a major contributing factor to Baby J’’s death was the interruption of his pressurised oxygen support CPAP machine on the date of his death. He also found that insufficient checks had been carried out on this support equipment, which was left in the care of a member of staff who was untrained in operating the equipment.
East Lancashire Hospital NHS Trust, the hospital trust that oversees the Royal Blackburn Hospital, issued a position statement immediately prior to the inquest commencing. This set out a number of admitted failings by the hospital, including that:
Closer liaison with both the cardiology team and the intensive care team would have been appropriate.
Failure to conduct appropriate checks on the CPAP machine and to refill the water reservoir caused the humidity levels to drop. This interruption to the machine led directly to the clinical deterioration of JP and the subsequent need for resuscitation.
The process of intubation and stabilisation carried out led to JP’s death. It is however unknown whether a decision to not intubate at that point or whether to intubate with the specialist team in attendance would have resulted in a different outcome.
There were issues with staff training, with staff left in charge of JP’s care lacking up-to-date CPAP training and that at the time there were no minimum standards of training for hospital staff caring for children with high dependency needs.
Baby JP’s family were represented throughout the inquest process by Kelly Darlington and the inquest team at Farleys, along with Andrew Bridgman, of St Johns Buildings. To speak to a specialist in our inquests team, please call 0845 287 0939, contact the team by email, or through the online chat below.