19th June 2025 – Bear Knight was born prematurely, by C – Section, on 17.08.23, at 30 weeks + 4 days.
His condition was satisfactory at birth but because of his prematurity he was transferred to the Neonatal Intensive Care Unit at the William Harvey Hospital Ashford, variously supported and treated there.
From Day 8 of life an intermittent tachycardia (racing heart rate) was noted.
On Day 13, 30.08.23, his heart rate was 223 at the morning ward round and noted to be unsettled across the day rising up above the 200s again in the evening. At around 22.00 his abdomen was “tense” upon examination. An x-ray taken at around 23.30 showed generalised dilated loops of bowel.
Bear continued to deteriorate overnight.
The decision to transfer him to London for urgent review and surgery was not taken until 08.00 the following morning. The transfer did not then occur until the late afternoon with Bear arriving at the Evelina children’s Hospital at around 16.00.
He presented with Abdominal Compartment Syndrome (excessive pressure within the abdomen) which was initially drained at 16.30. Upon proceeding to a full laparotomy at 17.30 the surgical team found a massive ischaemic event from the stomach to the colon.
It was not possible to operate effectively and Bear died the following day.
Death was attributed to gastrointestinal tract ischaemia, with the cause of the ischaemia remaining uncertain.
Concluding a 3 day Inquest into Bear’s death HM Coroner Katrina Hepburn found that there were multiple missed opportunities to review and escalate Bear’s deteriorating condition. In particular:-
- Antibiotic treatment should have been started earlier than it was.
- The on-call Consultant, Dr Munn, should have attended NICU overnight to review Bear himself; and
- A surgical referral to the Evelina Hospital should have been made significantly earlier.
A decision on whether to make a Prevention of Future Deaths Report has been reserved.
The family are represented by Fairweathers Solicitors LLP and by barrister Robert Cumming.
Speaking after the Coroner’s conclusion Nick Fairweather commented:- “This is such a tragic case and I pay tribute to the family’s courage and dignity in pursuing answers and justice for Bear. It is profoundly concerning that fundamental errors like these are still occurring in East Kent in this post Kirkup baby death.”
Bears’ mum Leah commented:- “The death of a child in any circumstances is an unbearable tragedy. To lose Bear as we did, however, at such a young age, when there were so many opportunities tohelp, support and potentially save him is beyond devastating. I am grateful to the Coroner for getting me answers, to my legal team and to the treating team at the Evelina who did everything that they could for Bear and reported his death to the Coroner. Unfortunately by the time he got to them it was too late due to the local failings. We miss and think about Bear every day and always will. He will always be part of our family. The missing person at the dinner table, at birthdays, on holidays and at every important point in our family’s future. We will always remember you Bear and wish you were here with us.”
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