A newborn baby who died of a catastrophic brain injury after being starved of oxygen for more than 40 minutes would still be alive today if Blackpool Victoria Hospital medics had given him proper care.
Blackpool Victoria Hospital
Finnley Morris was grossly neglected by staff when they failed to give him oxygen in an effective and timely manner after he was born ‘floppy, with no signs of breathing’ at 00.22am on October 1 2020. It was later determined he had suffered a hypoxic brain injury due to cord compression around the time of his birth.
Throughout an inquest at Blackpool town hall this week, the court heard how medics immediately tried to revive the newborn by applying ventilation breaths and chest compressions – but his airway was not secured and his heart rate remained low.
He was not intubated until 1.04am, by which time he had suffered an unsurvivable injury due to lack of oxygen. He was transferred to Royal Preston Hospital, where he died four days later.
Handing down a narrative conclusion to the case, coroner Alan Wilson said: “Finnley’s airway doesn’t appear to have been secured in a timely manner, which can be regarded as satisfying the requirement for breach of medical attention. It was believed the airway was secure and it was not, and this child was without sufficient oxygen and his heart rate below 60 beats per minute for a much longer period of time until intubation… This was not fully appreciated until it was too late.”
When paediatric consultant Dr Sunitha Peiris arrived at the scene 30 minutes after Finnley was born, she was shocked to find the baby – who she said was ‘floppy, with no signs of spontaneous breathing’ – had not already been intubated by medics, who were applying ventilation breaths and chest compressions.
She decided to intubate the baby, but could not find her reading glasses, which a nurse said delayed the process by ‘a matter of minutes’.
The registrar, Dr Suriya Dhulipala, volunteered to intubate Finnley instead. She said: “I immediately volunteered because I was confident I could do it.”
There was then a delay of approximately three minutes, as a clamp was missing from a tube on the resuscitaire, a device used to aid the resuscitation of newborn babies.
Dr Peiris said that she ‘did think about putting the tube in without the clamp’, but decided not to.
Ms Beel said: “Do you think that was the right decision?”
Dr Peiris replied: “Maybe not.”
Following the first intubation by Dr Dhulipala 42 minutes after birth, Finnley’s condition did not improve.
Nurse Hayley Knighton said: “I didn’t feel I could see the chest rising when they did the ventilation breaths. I think I said two or three times that I couldn’t see the chest movement.
“There was feeling, I think, from the doctors that the tube was in place and from what I could see I wasn’t sure that was the case.”
Eventually, the tube had to be removed and replaced by Dr Peiris. Further time was wasted as medics tried to locate a fresh tube, with Dr Peiris eventually deciding to reuse the same tube after a new one could not promptly be found.
Ultimately though, it was determined that these later delays had no impact on Finnley’s death, as by the time Dr Peiris arrived at the scene, his condition had already become unsurvivable.
Mr Wilson went on to say that, had Finnley received oxygen sooner, he would have survived. He said: “In the absence of this, a severe injury was sustainedand his condition became unsurvivable.”
He also raised issue with the lack of leadership during the attempts to resuscitate Finnley, following evidence from several witnesses, including trainee GP Samuel Esiere, midwife Rachel Sellers, and nurses Jacoba Eastwood and Hayley Knighton.
He said: “There was no leadership until the consultatn arrived.
“The registrar was placed in a difficult position… it does seem to me that this was effectively her first shift and she had not worked in this area for 12 months, which may have been underappreciated.”