Hospital blunders led to baby death

The alarm on the incubator was switched off

Separate mistakes at the same hospital led both to a woman giving birth very prematurely - and the subsequent death of one of her babies.

The case was highlighted in a report from the Health Service Ombusdman, who upheld two different complaints about care at Wordsley Hospital in Dudley, West Midlands.

The woman, named only as Mrs T, was known to be at a high risk of going into labour early, and went to hospital after suffering period-like pain and a discharge.

But a junior doctor at the hospital's maternity unit dismissed this as caused by an infection, and gave her antibiotics and painkillers.

She should have been given a drug to delay labour for as long as possible.

Shortly afterwards, she give birth to twins, who being very premature, needed to be given a drug to help mature their lungs as soon as possible.

Again, there was a delay setting this up at Wordsley.

Eventually, the boy and girl babies were transferred to the special care baby unit.

Alarm switched off

However, 10 days later, the sister in charge of the unit left them in the care of a nursery nurse.

The girl baby suffered a drop in heart rate below 100 beats a minute.

This normally triggers an alarm by the intensive care cot to alert staff, but the alarm on this cot had been switched off, and the problem was not noticed for some time.

The baby could not be resuscitated and died later that day.

She had previously been doing well, and been taken off the ventilator - but investigations revealed a blood test the night before showed an infection which should have meant the resumption of ventilation.

But this test result was overlooked by another junior doctor.

The Health Service Ombudsman's assessors said that the baby should not been left alone at all, let alone left alone with the monitor switched off.

All of Mrs T's complaints were upheld, and the hospital trust has apologised.

A spokesman said this week: "The trust has offered its apologies for the shortcomings in care received in 1996 by the complainant and one of her new born twins.

"The ombudsman was satisfied that the trust has taken steps since this time to reduce the likelihood of a re-occurrence."

The hospital has replaced the monitors in the neonatal intensive care unit and redesigned the unit so it is easier to keep an eye on babies.

Staffing levels have been improved in the maternity unit.

The ombudsman's report, issued on Thursday, highlighted a number of cases in which poor supervision of junior doctors had resulted in blunders.

Ombudsman Michael Buckley said: "There are many reasons why someone might not seek the support of a senior colleague.

"But it is clear from these reports that there were communication barriers between senior and junior medical staff."

The report highlighted other cases in which blunders were blamed for the deaths of patients.

Fast deterioration

Two involved cases in which the patient's condition deteriorated quickly over the course of the weekend.

In one, at Scunthorpe and Goole NHS Trust, an 81-year-old man's bowel obstruction was not diagnosed because the junior doctor left on call at the weekend did not respond to the concerns of nurses.

He died several days later after surgery.

"If he had been seen by a doctor earlier," the report concluded, "and been given appropriate treatment , the chances of a favourable outcome would have been greater."