3rd December 2021 – Archie Powell, died on 14th February 2019 at just 4 days old after a failure to administer life-saving antibiotics in a timely manner at QEQM. An Inquest has heard a number of criticisms of the care he received following his birth. The family were represented by counsel, Rose Harvey-Sullivan of 7BR, and our senior solicitor, Alex Tengroth.
Archie was the first of twins born naturally following induced labour at 37 weeks on 10 th February 2019 at 1:19am. There were no complications and Archie was deemed to be healthy at birth. His parents noticed him beginning to grunt, however, in the early hours of the morning and expressed their concerns to a midwife who first recorded them in her notes at 7:10am. She gave evidence to the Coroner that she requested a doctor’s review but her request went unanswered prior to handover when she finished her shift.
The Coroner determined that had a paediatric doctor reviewed Archie at this point he would have been admitted to the Special Care Baby Unit by 9am and antibiotics would have been administered by 10:30am.
Following handover the new midwife on shift also attempted to obtain a doctor’s review due to Archie’s continued grunting. Her repeated requests went unanswered until 9:25am when a paediatric SHO attended on Archie. They were informed of Archie’s history of continued grunting and poor feeding but determined on examination that there was no grunting or signs of respiratory distress and advised the midwife to continue to monitor Archie and encourage feeding. At Inquest, the paediatric SHO accepted that had he been sure Archie was grunting he would have requested Archie’s immediate transfer to the Special Care Bay Unit. It was also noted that the midwife did not voice her continued concerns following this examination.
Archie continued to grunt, his feeding remained poor and his temperature dropped below normal. It was established at Inquest that even without Archie’s grunting his feeding issues and temperature alone warranted a further paediatric review by 10:05am. This did not occur, however, and Archie’s condition continued to deteriorate over the course of the morning. Eventually, the decision was made to transfer Archie to the Special Care Bay Unit at around midday. Even that transfer was delayed so that he was not in fact admitted to the Special Care Baby Unit until 12:45pm, at which point his grunting had worsened with chest recessions and nasal flaring. The sepsis pathway was initiated but there was a further delay, likely due to a mis-communication between the staff caring for Archie, so that antibiotics were not administered until 3:50pm.
Sadly Archie continued to deteriorate. He was transferred to the specialist Evelina Hospital in London. There it was determined that he had sepsis due to a maternal Group B streptococcus (GBS) infection. Despite maximal treatment Archie sadly passed away on 14 th February 2019.
During the course of the Inquest further Trust failings were noted including:
1. Poor, inadequate and retrospective note keeping;
2. A lack of interdepartmental communication;
3. Failure by staff in positions of responsibility to escalate concerns and to react to escalated concerns; and
4. Under-trained and over stretched staff.
After 4 days of evidence in November 2021 the Inquest into Archie’s death was reconvened on 3 rd December 2021 when the Coroner, having had the benefit of expert neonatology and microbiology evidence, determined that Archie died as a consequence of a congenitally acquired GBS infection. She noted that the respiratory symptoms Archie was demonstrating at around 6 hours of age are a known indicator of infection and had this been picked up on and treated with antibiotics before midday on 10 th February 2019, as should have happened, Archie would have survived without injury.
Following the inquest the East Kent Hospitals University NHS Foundation Trust made a formal admission of liability stating that they accept that the care provided to Archie fell below what was expected and that it was these failings that caused his death. They offered their full apologies to the family and the civil case will likely now proceed to settlement.
Archie’s mum Dawn commented: ‘I am so grateful to Alex and Rose for guiding us through this very difficult time. The Inquest has enabled us to understand exactly what happened to Archie and how he was failed by the inadequacies of the Trust’s working practices within both the maternity and neonatal departments. We cannot forgive the management team within the Trust that had the power to stop this from happening; we cannot forgive the staff, doctors and leaders within the Trust who failed to see and react to the signs and symptoms that offered them multiple opportunities to save Archie’s life. Nothing can bring Archie back to us, but the Trust can change to ensure that no other family ever has to go through the pain of losing someone so wanted and so loved. It is our hope that the Trust will react urgently to put a stop to avoidable baby deaths that seem to have been an unfortunate regular occurrence, and put in place robust and safe working practices to ensure that no other parent has to go through the anguish of losing someone so deserving of love that can never be given.’
Alex Tengroth said: ‘This is a really tragic case in which the family have suffered the devastating, unnecessary and avoidable loss of their son, Archie. The repeated failings in Archie’s care on the morning of 10 th February 2019 cannot be excused, and I am pleased that the Coroner acknowledged this by reaching the conclusion she did within the Inquest process. Whilst the Trust’s subsequent formal admission of negligence is of course very welcome as it spares the family the separate ordeal of a contested civil claim, I consider it a great shame that the Trust has taken nearly 3 years to make a formal admission. As the family say, we must now hope that the Trust manages to significantly improve the level of care they provide within their neonatal and maternity departments to avoid such catastrophes in the future. ’
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