Hospitals admit blunders which ended in death of Tooting baby
Staff at two hospitals admitted a string of blunders that ended in the death of a three-month-old baby in a room where lights had failed.
A coroner at Westminster Coroners' Court decided Antonia Bloch died of natural causes despite the blunders at an inquest on April 17.
Despite diagnosing her with an infection when she was suffering from cardiac failure, serious communication failures and confusion among the resuscitation team, Coronor Dr Shirley Radcliffe criticised hospital staff for giving her parents false hope their daughter could live for years.
Antonina died in October last year of congenital heart disease, a condition she was born with.
The baby, who had a pacemaker, lived with her parents Katarzyna Bloch and Akadiusz Bloch, in Southcroft Road, Tooting, and was being treated by specialists in the Royal Brompton Hospital, Chelsea.
But on October 14 she was having problems feeding and was admitted to the paediatric ward in St George’s Hospital.
She remained in a stable condition, but took a turn for the worse on October 28.
A doctor decided to transfer her to specialists at the Royal Brompton and an ambulance was prepared for her.
She arrived at 2pm accompanied by a nurse, but it was a busy Friday evening and doctors did not see the tot until 5pm.
Her medical notes, which included her heart condition, were passed on to another staff nurse, yet doctors failed to locate them.
They checked the youngster over and diagnosed her with an infection, when she was actually suffering from the onset of cardiac failure.
There were also no free beds in the hospital.
Dr Anna Seale, paediatric consultant cardiologist at the Royal Brompton, said: "I did not expect her to deteriorate as she did. Communication could have been improved between the two trusts.
"I wish I had been more aware of the situation before that evening.
"I don’t think she should have left St George’s Hospital without knowing she was going to be admitted to a bed.
"I think they wanted her to come and stay and that message did not come through."
She was transferred back to St George’s Hospital with staff nurse Theresa Philips, who said the baby started looking blue in the ambulance and rushed to give her oxygen.
Medical staff attempted to resuscitate her at St George's Hospital, but the lights had failed in the room so portable lights had to be used and people were confused over their roles and what equipment was on the resuscitation trolley.
Antonina died just after 10pm.
Dr Martin Gray, a consultant paediatric intensivist at St George’s Hospital, was critical of hospital handover procedures and staff training.
He said: "I had grave concerns about it, absolutely yes. There were resuscitation difficulties, there was confusion how the equipment was in the resuscitation trolley.
"In retrospect if everyone knew where the equipment was I would have been a lot more efficient."
Coroner Dr Shirley Radcliffe said: "She was a very sick child, it was said there was not any information.
"At the end of the day, I don’t think the decisions made a lot of difference."
During the inquest, she criticised hospital staff for not making the parents aware of the severity of their daughter’s condition, giving them false hope the baby could live a longer life.
She said: "The first problem was that the parents were not informed of the seriousness of what their daughter’s medical condition was.
"I think it is very important the family should be told at a very early stage the seriousness of the prognosis and in this situation this was not made clear."
An investigation following the baby’s death was held between the two hospitals, with it being suggested there should be pamphlets or images for staff who might not have come across such a condition before.
It also found equipment should have been adjusted to suit the baby’s physiology and the transfer nurses should have confidence to speak to specialist staff.
Dr Radcliffe said: "There was a lack of understanding of the nitty gritty. I think we have to recognise that everybody was busy."