The treatment of a critical newborn was delayed by several minutes when the consultant “could not find glasses”


A newborn baby was deprived of oxygen for several minutes because a hospital consultant could not find his reading glasses.

An inquest into the death of Finnley Morris began today at Blackpool Town Hall Coroner Alan Wilson, hearing testimony from Finnley’s father, Adam Morris, and various midwives and nurses.

Emma Morris was five days past her due date on October 1 last year when doctors at Blackpool Victoria Hospital decided to induce her.

Ms Morris had contacted medical professionals two days earlier, fearing that her unborn baby’s movements had diminished.

Finnley was delivered at 12:20 am early in the morning, but doctors realized something was wrong when he didn’t cry and “looked like he was struggling to catch his breath.” Various delays led to a period of approximately 42 minutes before Finnley was intubated and began to receive oxygen.

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The newborn baby suffered irreparable brain damage and died four days later after being transferred to Royal Preston Hospital.

“Finnley did not immediately cry and he was limp with a slow heartbeat,” the coroner said.

“His father said there had been a 50 minute period without oxygen, he was transferred to Preston where an MRI showed swelling of the brain due to lack of oxygen. The doctor explained that his brain had unlikely to recover from hypoxic brain injury.

“He remained in the intensive care unit until his death on October 5.”

Two weeks after Finnley’s death, an autopsy was performed at the Royal Manchester Children’s Hospital by pediatric pathologist Dr Melanie Newbold.

She concluded that Finnley’s death was caused by severe hypoxic-ischemic encephalopathy where nerve cells in the brain die due to a lack of blood and oxygen supply.

“It is one of the most serious complications that can arise in the early stages of life,” Dr. Newbold told the video link investigation.

“It can cause death and even if the baby survives the immediate period, it is a life-limiting disease. It is caused by insufficient cerebral blood supply or oxygen to the brain.

“Once that happens, there is a cycle that begins; the initial insult causes the brain to swell and this causes another lack of blood supply. It accumulates more and more and the brain becomes so swollen that the brainstem is compressed and can no longer work. Once that happens, life cannot go on. “

Midwife Rachel Sellars said the direction of Finnley’s resuscitation “could have been a bit smoother”.

“I think maybe it could have been a bit smoother back then because I think it was the change of direction,” she said.

“I think because it was going on for a long time there was a change of direction and that’s why.”

Lawyer Victoria Beale, representing Finnley’s family, asked midwife Sellars: “Based on your experience as a midwife and your attendance at many neonatal resuscitations, do you think there was clear leadership?

“Due to the extent of the resuscitation, it was difficult to say if there was clear leadership as it changed from doctor to doctor,” she replied.

Another midwife who was present during the intensive efforts to resuscitate Finnley was Marie-Laure Longy who said she noticed that the initial breaths given to the baby were not being delivered correctly.

“If after the first five breaths you do not see any movement of the chest wall, you must wonder if the baby’s head is not in the correct position or if the mask seal is not properly adjusted”, said she declared.

The investigation learned that after Finnley’s head position changed, breaths began to enter his lungs. Another delay was caused when doctors realized that one clamp was missing and another needed to be found.

Miss Beale asked midwife Longy: “Have you ever been to another resuscitation and there has been a lack of equipment?

“No, never,” she replied.

Staff nurse Jacoba Eastwood was called to the operating room when doctors realized Finnley was having trouble breathing. He was asked how long it took to find a new clamp to secure the resuscitation equipment.

“Maybe half a minute,” she told the inquest.

Nurse Eastwood said the ultraviolet lamp above Finnley “had never been turned on”, although midwife Longy claimed it had been.

She also agreed with the criticisms of the leadership of the medical team and said: “No one was directing what was going to happen at times.”

Nurse Hayley Knighton, who works in the neonatal unit, arrived at the theater nine minutes after Finnley’s delivery. She noticed the pressure reading on the resuscitator was lower than it should be, to indicate oxygen was being administered and “immediately expressed concern,” she told the inquest .

“When a breath was delivered (the pressure) was less than I expected to see,” Nurse Knighton said.

The on-call consultant Dr Sunitha Peiris had been paged and when she arrived at the hospital, around 30 minutes after Finnley was born, she asked doctors why he hadn’t already been intubated.

However, it took another 12 minutes until Finnley was finally intubated, with “several minutes” wasted because Dr Peiris could not find his reading glasses, the investigation has learned. During this period, Finnley remained “white and still”.

“The consultant did not have her reading glasses,” said nurse Knighton.

“There was a discussion about trying to get him glasses. I don’t think anybody had spare glasses.”

When asked if the delay in finding glasses for Dr. Peiris was just a matter of seconds, Nurse Knighton replied, “More like minutes.”

The investigation will continue tomorrow and is expected to last four days.

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