Bolton: Family heartbroken after death of 10-day-old baby

Following a four day inquest, Area Coroner for Manchester West, Peter Sigee concluded that there were ‘individual and systemic failures in the post-natal care of Kinglsey Olasupo’, who would have survived had he received the right medication.

Kingsley was born, along with his twin sister Princess who was born 27 minutes after him, at the Royal Bolton Hospital on April 8, 2019, but he tragically died on April 18, 2019, after suffering from meningitis and sepsis.

Following the hearing, Tunde Olasupo, Kingsley and Princess’ father said: “We want Kingsley to be recognised and remembered as the baby who put new and better policies in place.

Heartbroken family break down in tears after baby tragically dies

“We want the details of Kingsley’s case to be used in hospitals nationwide to prevent this from happening again.

“No amount of money in the world can ever replace Kingsley, our only wish is that no one else goes through what we have and are failed the way Kingsley was.

“We will not stop pushing for changes and one of the things we want to push for is a permanent memorial of Kingsley, to always remind the doctors and midwives that simple mistakes can lead to a catastrophic outcome.”

The Medical director of Bolton NHS Foundation Trust has apologised for the care the baby received and said changes had been made.

During day four of the inquest Louise Green – who is representing the family – requested that the coroner reach a narrative conclusion, highlighting the issue of neglect by ‘practitioners and systemically at the hospital’.

She added: “This case is a tragedy.

“The evidence tells us that there was a catalogue of failings when caring for Kingsley Olasupo.

Heartbroken family break down in tears after baby tragically dies

“There were multiple missed opportunities that Kingsley was at risk of infection, where screening and antibiotics were not commenced early.

“There were risk factors present when Kingsley was born that were not spotted and led to his death.”

Miss Green previously asked if midwife Amy Leigh was aware of the NICE guidelines recognising and assessing early onset neonatal infection after birth, where if two or more non red flag indicators were present, that there would be screening for infection and a course of antibiotics.

Ms Leigh said: “I don’t think I was aware at the time where the baby would get to be screened unfortunately.

“We are more readily available to screen for different infections now.

“I would have intervened if symptoms had persisted, and if I was looking after him for the rest of the day.

“I was just following the policy and chart we used, particularly because of hypoglycaemia.”

Miss Green criticised the type of chart that was used instead of the Newborn Early Warning System (NEWS), which was part of the hospital’s policy.

Miss Green added: “There was a lack of processes followed within the trust to support reactions to infections.

“If somebody had raised the risk of infection and Kingsley had been treated with antibiotics on day three, he would have survived.

“By the time he was screened and given antibiotics, it was too late.”

On day one of the inquest Ms Leigh gave evidence, who was one of the midwives on duty on April 8.

Heartbroken family break down in tears after baby tragically dies

She says she followed the hospital’s meconium policy (for two hours) and neonatal hypoglycaemic policy, but Kinglsey’s heart rate and respiratory rate was not monitored.

It was also revealed that there had been no checks by the paediatrician even when concerns had been raised about Kingsley’s temperature and feeding difficulties.

Ms Leigh noted that Kingsley had meconium, which usually happens before the baby starts to feed and digest milk.

However, this was wrongly picked up by an advanced neonatal nurse practitioner within two minutes of his birth.

Nadine Wilson was the midwife on the second day of Kingsley’s life, and she received a hand over from Lucy McCann on April 9.

During this time an early new-born check was completed at 2pm, where a rash was noted, but Ms Wilson didn’t consider it to be concerning.

Heartbroken family break down in tears after baby tragically dies

At this stage, Ms Wilson was concerned about Kingsley’s temperature and ‘slow feeding’.

She later developed a chart to monitor the frequency of Kingsley’s feeds over 24 hours, where she would report to the paediatrician if this became worse.

After noticing that the temperature still was not being maintained when removed from an incubator, and issues feeding, she said she spoke to the paediatrician who advised her on the best course of action.

She noted that no one had been to examine Kingsley at the time.

Ms Wilson added: “I felt that they should have come and checked the baby out.

“They thought his temperature was dropping because of coming out of the incubator without any clothes on.

“They suggested a sleep suit that would keep him warm and maintain his temperature better.”

Area Coroner Peter Sigee said: “In accordance with guidelines, Kingsley should have been assessed by a paediatric doctor within two hours of his birth and every day thereafter, and detailed observations should have been recorded for him.”

When Kingsley was assessed on April 10, he was able to regulate his temperature, and didn’t need an incubator any longer, but his feeds were still slow, and he was not receiving adequate feed for his weight and age.

The inquest heard that it was only on his fourth day of life that Kingsley’s case was escalated to a more senior doctor.

After Kingsley was transferred to the Special Care Baby Unit to help with his feeding, it was determined that screening for infection and antibiotic medication was not required, and this was not carried out.

On April 12, Kingsley was screened for infection, but it showed that there wasn’t an infection present, and that it was ‘an early onset infection which had been continuously present in Kingsley from the time of birth’.

Before Kingsley was screened, his temperature had increased from 36.7 to 37.8, so he was administered two ‘broad spectrum antibiotics’, and transferred to the Neonatal Intensive Care Unit.

When Kingsley’s condition worsened, his antibiotics were increased, and an analysis of cerebrospinal fluid from a lumbar puncture, indicated that Kingsley had meningitis, and his antibiotics were increased again.

Area Coroner Peter Sigee said: “If a doctor had seen and assessed Kingsley at any time from birth in accordance with the guidelines then Kingsley would have been screened for infection, first line antibiotics commenced and, within approximately 24 hours of screening, Enterobacter cloacae would have been identified as the infective organism, enabling full dosage of meropenem to be administered.

“If meropenem had been administered to Kingsley by the early hours of April 12 then he would have survived.

“The medical cause of Kingsley’s death was multiple organ failure, extensive cerebral necrosis and brain swelling caused by bacterial meningoencephalitis and bacterial sepsis (Enterobacter cloacae).”

In the opening of the full inquest, the father raised a series of concerns in relation to Kingsley’s treatment and care, asking why there was “no treatment plan in place” and a line of communication as to “what was going on”.

He also questioned why Kingsley had not been transferred to a specialist children’s hospital, or why blood tests weren’t carried out, and if the infection was spotted earlier, whether this would have changed things.

Although both twins were born healthy, they were slightly premature at 35 weeks, and Kingsley’s weight was below the 10th customised centile for his age.

Kingsley’s mum Nicola, and the father felt the hospital were “giving up on him” when they had to turn his life support machine off.

Recording a conclusion of natural causes contributed to by neglect, Area coroner for Manchester West, Peter Sigee said: “There were individual and systemic failures in the post-natal care of Kingsley, which meant that Kingsley was not assessed and treated for infection in accordance with applicable guidelines.

“Taken both individually and together, these amounted to a gross failure to provide basic medical care to Kingsley, and they were causative of his death.

“This has been a very sad and tragic case.

“The family are devastated by this, and there are so many affected by Kingsley’s life.

“Kingsley’s death was caused by a natural disease process contributed to by neglect.”

Discussions are expected to be held to draw a conclusion for a prevention of future death report, with the families’ areas of concerns outlined.

Francis Andrews, Medical Director at Bolton NHS Foundation Trust said: “On behalf of the Trust, I would like to offer my sincere condolences to Nicola and Tunde for the tragic loss of their little boy, Kingsley.

“We fully accept the outcome of the inquest and are truly sorry that our care fell below the standards that Kingsley, Nicola and Tunde deserved.

“We undertook a thorough and transparent investigation, and have reviewed our practices and made significant changes.

“Babies who are at high risk of infection on our postnatal ward are monitored more closely by the right specialists in order to better detect early infection.

“Nothing can take away Nicola and Tunde’s profound grief.

“Following the verdict today, the actions we have taken and the learning from this, we will continue to do all we can to prevent such a tragedy happening again.”