Baby boy who survived major surgery just two days after birth was killed by hospital blunder weeks later
- Two-month-old Ethan Cross was recovering well from major organ surgery just after birth
- Brain was fatally starved of oxygen after a breathing tube was inserted incorrectly
Last updated at 4:18 PM on 8th February 2012
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.
'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.
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'.
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 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.'