Royal Bolton: Baby died after 'medical attention' failure

Olly Vickers, from Little Lever, was just 20 weeks old when he died in February last year at Royal Bolton Hospital, where he had been born to parents Emma Clark and Michael Vickers the previous September.

Now, an inquest has concluded that baby Olly’s death had been caused by natural disease, contributed to by a brain injury caused by “neglect” from health staff.

Coroner Peter Sigee said: “There was a gross failure to provide basic medical attention  to Olly while he was in a dependent position between 7.55am and 8.40am on September 13 2021.”

He added: “This brain injury caused Olly to be unwell and it more than minimally contributed to his death.

“Olly would not have died when he did if this neglect had not occurred.”

Olly Vickers was born at Royal Bolton Hospital (Image: Newsquest)

Baby Olly had been born in good health on September 31 2021 and was placed skin-to-skin with mother Emma Clark, who had suffered a tear during the birth.

But during his and his mother’s care, Ms Clark was provided with a pillow under her arm, contrary to accepted midwifery practice.

She was also given gas for pain relief while her tears were being repaired and was not advised not to continue holding baby Olly while this was being done.

If Olly was going to be allowed to remain in contact with his mother at this time then a risk assessment should have been carried out, which the inquest heard was not done.

Olly was left in place while one midwife was repairing Ms Clark’s tears and a student midwife was busy completing medical records.

The inquest heard how during this period, Olly was not continuously observed and by any member of staff and that breast feeding should have stopped before 8.05am that morning.

When the midwife had finished she noticed that Olly had slid into a position where his airways had been blocked and he was “floppy and grey/blue in colour.”

Though staff managed to get oxygen into him via a ventilator, an MRI scan revealed he had suffered an “acute brain injury.”

Olly spent the next few months in hospital before being discharged to Derian House Children’s Hospice on January 10 2022 and then allowed to go home seven days later.

But he needed to be taken back the next month where he died on February 6.

Before the inquest that concluded this week, Bolton NHS Foundation Trust agreed to a series of facts, including that it was “more likely than not” his death could have been avoided if the suturing process had been delayed until after the first breastfeed or if “constant observation” had been carried out.

Olly’s bereaved parents now hope that lessons can be learned from the tragedy.

His mother, Emma Clark, said: “Olly was so strong and brave throughout his short life.

“He was such a funny and loving baby who filled our hearts with love.

“We will always treasure the memories we made with our precious boy.

“Words cannot describe the pain of losing him, it’s there every minute of every day.

“For this to be avoidable if all the guidelines had been followed compounds everything.

“We question whether if we’d gone to a different hospital on a different day Olly would still be here.

“We want to raise awareness of the need to listen to parents, to follow the guidelines, which are there for a reason, and to ensure staff are trained in the importance of these issues.

“Olly was our world and losing him is something we will never fully recover from.

“Lessons being learned from his death is the only hope we can cling on to.”

ALSO READ: Grieving parents 'looking for answers' after death of baby son at Royal Bolton

These sentiments were echoed by law firm JMW, which represented the parents.

Partner Jodie Miller said: “This is a harrowing case and has taken an unimaginable toll on Emma and Michael.

"We feel a finding that Olly’s death was contributed to by neglect was the only conclusion that could be reached on the evidence.

"Olly was born a healthy baby boy and Emma and Michael were full of joy and excitement about the future the family had to look forward to.

"However all of that was taken away from them when  the safety guidelines that exist to prevent this type of incident from occurring were not adhered to.

"All we can hope is that the action plan put in place by the Trust ensures that no other families have to go through what Emma and Michael have.”

For its part, the Trust has pledged to do all it can to ensure that tragedies like Olly’s death are avoided in future while consultant midwife Louise Tucker having told the hearing about the “robust” action plan that has been put in place since then.

Chief nursing officer Tyrone Roberts said: “Our thoughts and sympathies remain with Olly’s family following the tragic loss of their son.

“Since Olly’s death, we have implemented a number of changes to minimise the risk of such a tragedy happening again.

“We fully accept that the care we gave Olly and his family was not acceptable.

“Whilst nothing we say can take Olly’s family’s pain away, by continuing to do everything we have outlined, our expectation is that no family will have to experience this in future.

“We are incredibly sorry that these mistakes were made.”