Baby boy who survived major surgery just two days after birth was killed by hospital blunder weeks later
Two-month-old Ethan Cross was recovering well from major organ surgery just after birth
Brain was fatally starved of oxygen after a breathing tube was inserted incorrectly
A baby who survived major organ surgery died after being transferred to a hospital where 'bad failings' proved fatal, an inquest heard yesterday.
Ethan Cross was born with his organs outside his body, and underwent corrective surgery aged just a few days old.
Two months later he was on the road to recovery but a hearing was told that his brain was fatally starved of oxygen when a breathing tube was inserted incorrectly.
Tragic: Ethan Cross, who was recovering well after major organ surgery, died after 'bad failings' by hospital staff an inquest heard
At the inquest, deputy coroner Andrew Cross described that staff at Derriford Hospital, Plymouth 'failed collectively' to save Ethan's life.
He also noted a lack of experience and confidence in a new doctor who was expected to take charge of the emergency.
Mr Cross said: 'In my view there were failings, bad failings even. There was not, however, a total and complete failure.
'Individually competent people failed collectively in this critical situation.'
Ethan was born on September 7, 2009 at a specialist hospital in Bristol because doctors
were aware some of his organs were growing outside his body.
Aged just a few days old he underwent a major operation to place his organs back inside his body.
The inquest heard that, despite a number of minor incidents, he was no longer considered to be in a life-threatening condition and was transferred to Derriford Hospital, Plymouth on November 6 and put on a ventilator.
However the two-month-old died on November 14 2009 when a breathing tube that had become dislodged was replaced too slowly.
A spokesperson for Plymouth Hospitals NHS Trust described that a series of robust changes have now been made at Derriford Hospital
Staff in the neonatal intensive care unit that night included an experienced staff nurse who was tasked with giving Ethan one-to-one care, and a ward sister who had worked on the unit for ten years.
There was also two new doctors, a specialist registrar in charge of the ward and a senior house officer. A consultant was on call for the ward when the the 'critical event' happened at around 4am on November 7.
Mr Cox said the 'likely trigger' was that Ethan’s breathing tube became displaced from his windpipe into his oesophagus.
He noted that staff’s initial response was 'appropriate', including Ethan being given oxygen and increased ventilation and that the consultant, who was telephoned at about 4.15am, was called at the right time.
However, before the consultant arrived, the registrar failed to provide 'confident clear leadership'.
This was a very sad case and we are extremely sorry that there were failings in the care given to Ethan
He described staff had relied too heavily on listening to Ethan’s chest to check whether the tube was in place – a method an expert witness had described as 'notoriously difficult'.
Mr Cox said the registrar’s actions demonstrated 'little experience' of the specialist skills required.
The tube was finally removed on the advice of the consultant, who was travelling to the hospital. He arrived shortly afterwards and replaced it, but by that time it was too late.
Mr Cox recorded a verdict of death by misadventure. Ethan’s mother Shelley Cross, 29, attended the inquest but declined to comment.
Robert Antrobus, who represented the family during the inquest, said: 'The family are grateful to the coroner for his thorough review of the events leading up to Ethan’s death.
'Sadly the coroner, delivering a verdict of misadventure, has found evidence of substandard care which has played a significant part in baby Ethan’s death.
'The family does however acknowledge that the Trust have undertaken a full investigation which highlighted problems with Ethan’s care through its serious untoward incidents (SUI) procedure.
'The family sincerely hope that the lessons learned in this tragic case result in other families not having to go through what they did.'
The hospital has since apologised, stating that they are 'extremely sorry that there were failings in the care'.
A spokesperson for Plymouth Hospitals NHS Trust said: 'We offer our sincere sympathies to the parents and family of baby Ethan.
'This was a very sad case and we are extremely sorry that there were failings in the care given to Ethan.
'As the coroner noted during the inquest, we had undertaken a full investigation into what happened and, as a result, we have made a series of robust changes within our neonatal intensive care unit during the past year.'