Baby boy who survived major surgery just two days after birth was killed by hospital blunder weeks later
The hospital put an inexperienced doctor in charge who was out of his depth in a specialist unit — and he got it wrong and killed a baby
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.
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.
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’.
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.’
Literacy in English schools at ‘Dickensian-era levels’ warns minister as classics are ignored
Dickensian levels of illiteracy still plague parts of England despite decades of increases in state spending on education, a minister declared yesterday.
Schools Minister Nick Gibb said ‘shadows of Charles Dickens’s world’ persisted in the country’s poorest areas despite major social advances. Expectations of children moving through the school system were too ‘modest’, with teachers settling too often for a ‘good enough’ standard, he claimed.
The result was under-achievement by thousands of youngsters, with one in six still struggling to read fluently by the age of 11.
In a speech on the 200th anniversary of the author’s birth, Mr Gibb warned that, just as in Victorian times, literacy problems were ‘heavily orientated towards the poorest in our communities’. ‘We need – if you’ll forgive the Dickens pun – much greater expectations of children in reading,’ he added.
He also said pupils at primary school should be encouraged to read ‘complex’ books by authors such as Michael Morpurgo, Jacqueline Wilson and Roald Dahl, while secondary pupils should read at least one Dickens novel during their teens.
Classic works of literature were being ignored, he warned, with tens of thousands of pupils gaining GCSEs in English literature without studying any books written before the 20th century.
More than 90 per cent of answers on novels in English literature papers were on the same three works – Of Mice and Men, Lord of the Flies and To Kill a Mockingbird. Out of more than 300,000 who took the country’s most popular paper last year, just 1,236 read Jane Austen’s Pride and Prejudice, 285 read Thomas Hardy’s Far from the Madding Crowd and 187 read Emily Bronte’s Wuthering Heights.
‘Unfortunately, even when young people do wish to read, the exam system does not encourage them,’ Mr Gibb said. Despite a wide curriculum, ‘the English Literature GCSE only actually requires students to study four or five texts, including one novel’. He also claimed children in England were ‘falling out of love’ with reading.
A study of 65 developed nations ranked the UK at 47th for the number of children who read for pure enjoyment, he said. Some 40 per cent of pupils did not read for pleasure, against just 10 per cent in Kazakhstan and Albania.
Mr Gibb said the current target set for 11-year-olds at the end of primary school – that they reach level four in reading – was too ‘modest’. Youngsters should aspire to the elite level five, he said.
A survey of 500 employers by the Confederation of British Industry last year found that 42 per cent were dissatisfied with school-leavers’ basic skills, while army recruiting officers have warned that hundreds of would-be soldiers have been turned away for failing basic literacy and numeracy tests.
Mr Gibb’s speech came as he launched a national reading competition designed to encourage seven to 12-year-olds – especially boys – to read more fiction.
British Gov. Bans Christian Group From Advertising That God Can Heal Illnesses
I wonder when they will crack down on the Prince of Wales’ “Duchy originals” — which is a line of quack medicines
Faith healing comes with a fair share of controversy. For some non-believers, the notion that a higher power would intervene to heal the afflicted it patently absurd. For some believers, even, the practice seems somewhat above and beyond the earthly realm of possibility.
Yet for others, faith healing is an important tenet that showcases the full power and ability of the Almighty. But in England, the government is agreeing with the former cohorts, as an agency is cracking down on the notion that God can cure those in need.
The Advertising Standards Authority (ASA), Britain’s media advertising watchdog, has banned a Christian group from making claims on its web site and advertising brochures that God can cure a number of ailments, RNS reports. According to the ad authority, the group Healing on the Streets (HOTS) Baths was being both irresponsible and misleading in its stated claims about God’s power to heal.
HOPS Bath has claimed that ulcers, depression, allergies, asthma, paralysis and sleeping disorders, among other illness, can be cured by the Lord. After an anonymous individual complained about one of group’s leaflets, the ASA investigated and concluded that the ads “could encourage false hope and were irresponsible.” The leaflet reads:
“Need Healing? God can heal today! Do you suffer from Back Pain, Arthritis, MS, Addiction … Ulcers, Depression, Allergies, Fibromyalgia, Asthma, Paralysis, Crippling Disease, Phobias, Sleeping disorders or any other sickness?
The BBC has more regarding the group’s reaction
“It seems very odd to us that the ASA wants to prevent us from stating on our website the basic Christian belief that God can heal illness.
“All over the world as part of their normal Christian life, Christians believe in, pray for and experience God’s healing; our ministry, in common with many churches, has been active in praying for God’s healing (of Christians and non Christians) for many years.”
The group said it had tried to reach a compromise, “but there are certain things that we cannot agree to – including a ban on expressing our beliefs”.
The ASA has distinguished itself as extremely strict when it comes to oversight. In fact, it‘s considered among the world’s most stringent advertising oversight agencies.
The British army under fire from elf’n’safety and a busybody culture making babies of us all
Once upon a time, when a man chose a career as a soldier, everybody — including himself — knew he was making a deal. In return for more excitement, travel and adventure than he would get as a bank clerk or supermarket manager, he put his life on the line.
Not any more. Last week, the head of the Army, General Sir Peter Wall, made a speech in which he deplored the growing public belief that if wars are fought right, nobody gets killed.
‘I sense there is an expectation in some circles in society that the sort of zero-risk culture that is understandably sought in many other walks of life ought to be achievable on the battlefield,’ he said.
Sir Peter’s dismay is widely shared in the armed forces, and among senior veterans. Recently, I heard General Sir Michael Rose, who commanded the SAS in the Falklands, deplore the new ethic created by coroners, human rights cases and media pressure, which he believes to be gravely damaging the Army as a fighting service.
The plague virus of health and safety is seeping into the military, as into every aspect of British life. We are conditioning ourselves to believe that with proper management, we can eliminate risk. Yet as we slither down this sorry road, we diminish the quality of all our lives, and especially those of the young.
For the past month, I have been shooting a documentary for BBC TV, to mark the 30th anniversary of the Falklands War. Again and again during filming, small incidents and exchanges have reminded me how much the world, and especially our society, has changed its attitude to risk since 1982.
First came Mike Rose’s remarks before the camera about risk-aversion. Then we went to view construction of one of the Royal Navy’s new carriers at Rosyth.
Before entering the shipyard, as at almost every modern industrial facility, we had to watch a ten-minute health and safety video. Its message could have been conveyed in ten seconds: wear a hard hat, behave sensibly and watch out.
But the company’s lawyers obviously advise that unless every visitor views a childishly exhaustive safety briefing, the yard could be vulnerable to litigation from one of the vulture flock of compensation lawyers that now crowd the courts.
Next day, we were filming Royal Marines cliff-climbing at a quarry in Argyll. I hate heights and am getting old and clumsy. As I made my way along a slate face to shoot a sequence, I gazed uncomfortably down 80ft or so and thought: ‘If I am fool enough to slip and fall, who will get sued? The BBC or the Ministry of Defence?’ I mean, nobody made me wear a safety harness.
I was tempted to stop and write a last will and testament saying: ‘If I break my neck, I want absolutely nobody to get blamed.’ But even then, some idiotic coroner would probably decide that I could not have been of sound mind to say such a thing, so somebody should be blamed anyway.
It is madness, and most of the young realise this. We filmed a group of teenage schoolchildren from Somerset talking about their attitude to history, and to the Falklands. Several of them said, unprompted, that they regret everybody is now so desperate to avoid exposing them to danger that it is much harder for them than it was for our generation to have adventures — which every right-thinking boy or girl wants to do.
I was thinking of their remarks last week, reading accounts of the tragic deaths of the two Essex schoolchildren Olivia Bazlinton and Charlotte Thompson on a level crossing in 2005. Network Rail admits breaches of health and safety regulations, for which the company faces heavy fines.
Yet am I the only person in Britain who asks the question: ‘Why did they not stop and think before crossing the line when red lights were flashing and yodel warnings sounding?’
It is utterly understandable that their parents, distraught with grief, dismiss suggestions that the girls behaved recklessly. But it seems to me that we now expect government and public bodies to protect us all, and especially children, from even the most ill-advised personal actions.
As a teenager, I sometimes did foolish things on and around railway lines because I liked to live dangerously. But I did not doubt then, and do not doubt now, that if anything had gone wrong and I had been injured or killed, blame should have rested solely with me.
Last autumn, my wife and I were among a group visiting some wonderful castles and monasteries along the Black Sea coast. We made jokes about the fact that, in Turkey, Georgia and Ukraine, we could clamber freely on rickety medieval buildings above sheer mountain drops. In Britain, alas, they would be rigorously fenced off as a threat to public safety.
The National Trust and its staff have suffered shockingly from harassment by the Health And Safety Executive, not least in respect of trees, of which you may notice the Trust owns quite a few.
At one point, a senior NT executive was moved to demand of an H&S gauleiter: ‘Are you expecting us to fence off every tree on our properties in case a branch falls on somebody?’ And by gosh, these tyrants came close to demanding just that.
We should recognise the punitive cash costs we inflict on ourselves by demanding that life should become inexorably safer, safer, safer. The railways are statistically our least perilous means of travel. But every time a fatal accident takes place, following a hue and cry, Network Rail or the regional companies are bullied into spending millions of pounds installing new equipment to insure against any repetition.
It would never occur to us to make the same demands, following car accidents such as happen every day. Expenditures on safety are often wildly disproportionate to risk.
But the real price of health and safety madness is paid by all of us as people, morally enfeebled. If we accept no personal responsibility for our actions — and even children are perfectly capable of bearing some — we become sheep, fit only to be herded from pen to pen.
As for soldiers, to return to Sir Peter Wall’s speech last week, it is almost demented for the media, civilian coroners and judges to try to make their trade as safe as stacking supermarket shelves. Almost every man who serves in Afghanistan admits to the buzz he gains from combat — precisely because it is dangerous.
Although the Army has had to fight its recent campaigns amid a deplorable shortage of helicopters, we should ignore much of the claptrap about alleged equipment failures: our soldiers in Afghanistan are the best-equipped Army Britain has ever put into the field.
If their kit is not perfect, it is because nothing ever is. If commanders sometimes make mistakes which cost lives, and earn magisterial rebukes from ignorant coroners, this is because young men do make mistakes, and in war the price is paid in blood.
I often deplore my generation moaning about how Britain is not what it was in our younger days. We must sometimes bow to the spirit of a new century; certain things have got better.
But the spreading pollution of the blame culture, the corrosion even of the spirit of our fighting men by health and safety, seems wholly deplorable. It suggests a society in moral decline, which aspires to make babes in arms of us all.
Aspirin ‘not to blame’ for stomach bleeding – that’s due to a bug, say scientists
This is a rather exciting challenge to some long-accepted wisdom
Thousands of patients are unable to take daily aspirin to prevent heart attack and stroke, because of the risk of stomach bleeding. Instead, they have to be given more expensive and sometimes less effective treatments.
But, now, scientists have identified what they think is the real cause of stomach bleeding linked to aspirin — a common stomach bug. This new theory could transform the way many people with cardiovascular disease are treated.
It also opens up the possibility that otherwise healthy people, who are currently advised not to take a daily aspirin, because of the risk of bleeding, might be able to take it safely for its cancer-preventing benefits.
Low-dose daily aspirin is a lifesaver, helping to prevent blood clots in the arteries supplying the heart and brain.
It is also prescribed for problems such as atrial fibrillation, a common condition that causes an irregular heartbeat, as this can also lead to the formation of blood clots. More recently, the drug has also been linked to a lower risk of cancers.
However, it does carry the risk of abdominal pain and stomach bleeds, and for this reason many patients are advised not to take it.
This risk was thought to be due to aspirin directly irritating the stomach lining and causing an ulcer. Now researchers from Nottingham University believe that helicobacter pylori bacterium (H. pylori), a common stomach bug, may in fact be responsible for the ulcers — and that aspirin merely exacerbates them.
The scientists think treating this problem at the source by eliminating the bacteria would leave more people able to tolerate aspirin, and so reduce their risk of heart attack and stroke.
One in four people is infected with H.pylori at some point, and though many people show no symptoms, it is thought to be the principal cause of stomach ulcers: about three in 20 people infected with it develop a stomach ulcer.
Now research has also linked the bacterium to bleeding from aspirin. In a study by Nottingham University, 60 per cent of patients who suffered internal bleeding while taking low-dose aspirin tested positive for the bacterium (H.pylori is detected using a breath test).
As the researchers explained: ‘Our hypothesis is that H.pylori causes the ulcer, and aspirin, by thinning the blood, makes it bleed. ‘If the bacterium is eradicated, the patient will not get an ulcer and therefore there is no increased bleeding risk with aspirin.’
Now a new trial of 40,000 UK patients will investigate this. Doctors at five universities across the UK — Oxford, Durham, Southampton, Birmingham and Nottingham — will carry out the trial, the Helicobacter Eradication Aspirin Trial, starting next month and ending in March 2016.
In the study, patients aged 60 and over who are taking low-dose aspirin will first be given the breath test for the H.pylori bacterium.
Those found to be infected will receive a one-week course of eradication drug treatment of strong antibiotics, or a placebo treatment.
Commenting on the study, Dr Jonathan Lyne, a consultant cardiologist who practises in London and at the Mater Private Hospital in Dublin, said: ‘Aspirin is a cornerstone of treatment in almost all patients with vascular disease.
‘Concern in using this drug in those with a history of stomach ulceration and bleeding has always led to consideration of not using it in these patients, or using alternative drugs that may be more expensive and potentially not as effective.
‘Furthermore, the potential cost savings in preventing hospital admissions, investigations and treatments related to ulcers and bleeding caused by aspirin and H.pylori would be welcome not just to patients but to the NHS as a whole.’