Eight recommendations have been made in the Significant Adverse Event Review (SAER) report, and health bosses will also be apologising to the girl’s family.
The baby was described as being “floppy” and having difficulty breathing when she was born, and was later making a “grunting” noise while having difficulty feeding.
Neonatal care at Caithness General Hospital is provided by the midwifery team, in contact with staff at Raigmore Hospital in Inverness.
Caithness General does not have alternative staff with neonatal training, and the report found that this led to a delay in IV access, provision of IV fluids, IV dextrose and IV antibiotics.
The external review group, from NHS Borders, concluded that it would “never be possible to say whether earlier antibiotic treatment would have altered the eventual outcome”, but it added that “this possibility can’t be ruled out”.
The report continued: “It would appear that the midwives in Caithness and the medical staff in Raigmore involved in the care were conscientiously considering the best way forward and trying to make the most appropriate plan. With the benefit of hindsight however antibiotics, in accordance with guidelines, could have been started anywhere up to 26 hours prior to the time of the first dose, and more reasonably perhaps 16 hours before.”
NHS Highland has already implemented some of the recommendations in full or in part.
Medical director Dr Rod Harvey said: “This extremely sad case had a devastating outcome for the family concerned. We are determined to do all we can to ensure that something like it does not happen again. Some of the overall deficiencies in the process of care were identified and a series of measures have been identified to minimise or prevent as far as possible a similar tragedy recurring. We are determined to embrace these measures in full and have already made a number of changes.”
Steps will also be taken to minimise the chances of an infant requiring neonatal paediatric support being delivered at Caithness General.
NHS Highland has put in place interim measures – including a temporary restriction on deliveries undertaken there – until a decision on the final configuration of maternity services there is made.
Efforts are also being made to improve the detection and management of unwell new-born babies at the hospital.
The report called for further information regarding the safety of neonatal care at Caithness General.
A public health-led review of the service, supported by expertise external to NHS Highland, will be undertaken to inform the future configuration of maternity services at the hospital.
Dr Jean Turner, chief executive of Scotland Patients Association, said: “This is a terrible tragedy. They need to really figure out what kind of safe maternity services they can provide at Wick. It is a very long journey from Wick to Inverness. The important thing is communication and being able to be aware that somebody like a young baby is ill, and being able to get the right kind of help very quickly. This is very sad and it won’t bring the child back. It may or may not have been able to have been avoided. You can’t bring babies back but you can try to make sure that all that could be done was done and it won’t happen again.”
The SAER report has been shared with the family concerned.
Recommendations made in the report
- There should be an active statement recognising that this is an extremely sad case, and with a clearly devastating outcome for the family.
- Steps are taken to minimise the probability that an infant requiring neonatal paediatric support is delivered in Caithness General Hospital.
- Steps are taken to improve the detection of and management of the unwell neonate in Caithness General Hospital.
- Develop multi-disciplinary education and training matrix for all key clinicians in Caithness General Hospital.
- Develop a mutually agreed “escalation of concerns plan” to be utilised if there is doubt about opinion or advice.
- All contacts regarding any neonates must be direct from midwife to paediatric consultant or when available, advanced neonatal nurse practitioner.
- A public health-led review of the safety of the neonatal care service, supported by expertise external to NHS Highland, must be undertaken to inform the future configuration of maternity services in Caithness General Hospital.
- A formal apology should be made to the family and ongoing communication and support should be made available to them.
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23 September 2016
WARNING: GRAPHIC IMAGES. Emma Edwards is furious after her daughter Karmen was left with a one-and-a-half inch scar,
A surgeon accidentally sliced a baby’s head during a caesarean section leaving the infant with a huge scar after doctors took 24 hours to stitch up the wound.
Emma Edwards’ daughter Karmen has been left with a one-and-a-half-inch scar between her eye and ear as a result of the blunder which is now being probed by health chiefs.
The mum said a locum doctor who made the incision claimed she had not been told that Emma was in labour as she performed the procedure.
Emma has been left traumatised by the incident which had been followed by a series of upsetting delays to the operation.
And she was also put through an agonising 24 hour wait for a plastic surgeon to come and stitch her newborn’s wound.
The 21-year-old said the mistake could have had far more serious consequences – and claimed the care she and her baby received had been a “disaster from the start to the end”.
Emma travelled from her home in Wick, Caithness, the day before with her partner, George McPhee, 26.
She said: “We went to the hospital on Thursday morning, about 8am. The hours kept passing and kept passing. Eventually at 5pm they said ‘we can’t do it because there are too many emergencies’. Then they promised me it would be first thing on Friday morning, so we stayed overnight again. Nobody came to me until about 12pm that day, then they cancelled again. It was just a disaster from the start to the end.”
The family returned to Wick on the Friday night before having to travel back to Inverness on the Sunday evening so she could have her baby on the Monday morning.
But at 3am her waters broke, and she went to Raigmore three hours later.
She added: “When I went in I passed on to the midwife that my waters had broken at 3am and I was in a lot of pain, I was contracting, but they didn’t look me over. At 10am I was ready. I went down for my section and everything was fine until after they delivered the baby. They rushed her off to SCBU (special care baby unit) because they had cut her head. The surgeon came and spoke to me afterwards and said that it happened because I hadn’t told anyone that my waters had broken and was in labour, but I checked my medical records and it said that I had explained that. There’s a maternity unit right on my front doorstep but they just can’t do anything. My family had to travel down on the Thursday and then they had to travel back and then down again. It’s expensive. They want a meeting to speak about what happened. They’re launching an investigation into the surgeon because she doesn’t work for NHS Highland. She was a locum.”
The cut on the baby’s head was not stitched up until the following day because the hospital had to wait for a plastic surgeon to arrive from Aberdeen.
A health board spokesman said an internal investigation is being carried out into the incident.
He said: “NHS Highland does not comment on individual cases. We are carrying out an internal investigation into this incident.”
Details of the blunder emerged amid an ongoing controversy over expectant mums from Caithness having to travel more than 100 miles to Inverness to give birth.
The threshold for sending mothers to Raigmore was lowered last year after a baby girl died of the E.coli sepsis infection just 40 hours after being born at Caithness General Hospital in Wick.
A recent study of almost 900 women who underwent C-sections showed that between 1.5 per cent to 1.9 per cent of the infants experienced cuts.
Nicola Sinclair, secretary of the Caithness Health Action Team campaign group, said it was a “distressing” case which “highlights the dangers of cutting services to remote areas”. MIRROR