Coroner rules misadventure at inquest into death of four-day-old baby from Gravesend
A four-day-old baby who suffered a "catastrophic and extremely rare" brain injury at birth died as a result of misadventure, an inquest has ruled.
Vincent Rewers was delivered by ventouse, a vacuum-like device, at Darent Valley Hospital on October 4, 2012, but died at King's College Hospital in London, on October 8.
The two-day inquest at Gravesend's Old Town Hall heard from consultant paediatric pathologist Liina Kiho who said it was "probable" that the instrumental delivery was a significant cause for the baby's head injury, which included several skull fractures, and subdural haematoma.
Old Town Hall in Gravesend High Street
This is a serious brain condition when blood collects between the skull and the surface of the brain.
The hearing was also told there was "considerable delay" in transferring the critically ill baby from the hospital in Darenth Wood Road to the specialist neurology unit at King's College.
Consultant paediatrician Abdul Hasib told the hearing of his "desperate" attempts to arrange for an ambulance with the necessary neonatal equipment to undertake the urgent journey.
However, none of the three teams that cover Kent, Sussex and Surrey and provide such a service was available as they were dealing with other emergencies.
A suggestion to transfer him in a hospital ambulance with an anaesthetist on board performing hand ventilation was "absolutely unacceptable".
The inquest heard it took almost five hours from when the decision was made to move Vincent to King's College for him to arrive there.
By this stage he was brain dead on the left-hand side and surgery posed a substantial risk.
Even if he had survived an operation, he would have had profound disabilities and be unable to walk, speak or see.
At one stage a consultant at the London hospital contacted Darent Valley to remind them of the need for urgency.
But it was accepted by coroner Roger Hatch that the delay made no difference to his chances of survival.
Darent Valley Hospital in Dartford
His condition was said to be "extremely rare" and, even before agreeing to admit the newborn, the neurosurgeons at King's College had told doctors at Darent Valley he had a very poor prognosis and was unlikely to survive.
His parents, Karolina Rewers, 23, and Louis Rogers, 29, of Milton Road, Gravesend, had also been given the devastating news.
Recording his verdict, Mr Hatch said: "I am satisfied that while at Darent Valley Hospital the care and treatment Vincent received was appropriate and the development of the bleed (to the brain) was diagnosed shortly after the symptoms were found and subsequently confirmed by the CT scan.
"On the balance of probabilities it follows from this that the time it took for him to be transferred to King's College in no way affected the final outcome."
The coroner also said that Dr Hasib had done "everything possible" to arrange a transfer.
He added: "There are always risks in childbirth and sadly in this case, despite the considerable efforts of those involved in the care, it proved impossible to avoid the tragic death of Vincent."
Vincent was the couple's first child. They were present throughout the hearing, together with Vincent's grandparents, but declined to comment after the verdict.
Clinical gynaecological registrar Dr Grace Asante-Duah, who delivered Vincent, described his birth as "easy and straightforward", requiring just two pulls with the ventouse.
Despite weighing less than 5lbs, he was said to be healthy with no visible markings or swelling to his head.
She told the inquest an instrumental delivery was needed when Vincent's heart rate dropped, indicating foetal distress.
Repeated calls were made for ambulances to transport the new-born
Dr Asante-Duah said the decision to perform a ventouse procedure was based on the quickest and safest way for him to be born in light of the clinical findings.
She added it was one she had performed frequently and the risks involved were discussed with the baby's parents.
Complications set in while Miss Rewers and her son were on the postnatal ward. Vincent had difficulty feeding and developed low blood sugar levels.
He started to suffer from fits and was admitted to the hospital's special care baby unit a day after his birth, where he was treated for suspected meningitis.
However, when the fits continued, Dr Hasib was consulted and he requested a CT scan.
"There are always risks in childbirth and sadly in this case, despite the considerable efforts of those involved in the care, it proved impossible to avoid the tragic death of Vincent" - Roger Hatch
This revealed the extensive brain bleed and the decision was taken that he needed to be transferred to a specialist neurosurgical unit.
Miss Rewers’ pregnancy was said to have progressed “unremarkably” until 37 weeks when it was discovered she was small for her dates.
A scan was arranged for October 6, 2012, but she went into labour on October 3 when she was more than 38 weeks pregnant.
The inquest heard that Vincent's parents later wrote to Darent Valley raising several concerns, including both the delay in carrying out a CT scan and transferring the baby to King's College on October 5.
They were told during the hearing that "lessons had been learned" which had led to improvements in both areas.
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