A doctor made a ‘fundamental error’ by not replacing a premature baby’s breathing tube as her stomach swelled with air, an inquest heard.
Tiny Summer Hawcroft was on a ventilator in Barnsley Hospital’s special care baby unit in May 2011 when the tube dislodged, starving her lungs of oxygen.
She went into cardiac arrest and was resuscitated but later died aged just 49 days old in Sheffield’s Jessop Wing.
During her inquest at Sheffield Coroner’s Court, which resumed yesterday after being adjourned last year, Professor Simon Mitchell said that paediatric consultant Dr Vishwanath Kamoji, who was the senior doctor treating Summer on May 4, had made a ‘fundamental clinical error’ by not removing Summer’s breathing tube early enough.
He said that, in his opinion, the first thing a doctor in that situation should do is to check that the tube was positioned correctly. He said he agreed with the practice of ‘if in doubt, take it out’. It was clear there was a failure to diagnose the tube had become dislodged,” he said.
“That Dr Kamoji did not reintubate within the first few minutes of assessing Summer was a fundamental clinical error.”
He added that he was sure ‘beyond a reasonable doubt’ that the delay in repositioning the tube had led to Summer’s death.
The court heard Dr Kamoji had been given information from nurses who suggested replacing the tube, but he had instead ordered an X-ray of Summer’s chest - which he then failed to look at - and called for a second opinion.
“It struck me as unusual that a second opinion would be needed in the circumstances,” said Dr Mitchell.
However, when asked by Coroner Chris Dorries if he thought Dr Kamoji’s actions amounted to gross negligence, Dr Mitchell said: “My gut instinct is to say no.”
Summer was born prematurely at 27 weeks to Michaela Hawcroft, 26, and her husband Stephen, 37, of Kendray.
The inquest continues.