Baby death: Sheffield coroner rules that hospital doctors must listen more to parents and nurses

Kyra Ali Aslam, aged five months, died in August 2022 at the hospital. Her causes of death were related to surgery to reverse a stoma, which collects body waste from the bowels. This was put in place when Kyra was a newborn baby.

Assistant South Yorkshire coroner Abigail Combes, who investigated the little girl’s death, has raised various concerns through a prevention of future deaths report.

She said: “Kyra did not recover from the surgical intervention, deteriorating relatively rapidly over the course of two days.”

The coroner said that the hospital authorities must consider “whether there is a culture which prevents medics from taking account of the views of parents or nursing staff when considering the overall presentation of patients”.

She also said: “Where a junior doctor is overruled by a consultant, is that learning adequately explained to that junior doctor to learn for next time?”

Significant

The report said: “Kyra was unwell after the surgery and her mother was identifying that she was not behaving either how she normally would or how she had after her earlier surgery which Kyra’s mother had been led to believe was a much more significant surgery.

“Kyra’s mother’s concerns were explained by the medical team as matters which were normal within the context of pain, anaesthetic response and surgery.

“On the balance of probabilities I find that insufficient weight was placed on Kyra’s mother’s concerns. These ought to have been more clearly explored with her to understand whether there was anything in ‘mother’s intuition’ that ought to lead medics to consider alternative causes for Kyra’s presentation.

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“However, in the circumstances, the explanations preferred by the medical teams were within the context of reasonable medical opinion and therefore I am satisfied that on August 11 the insufficient weight placed on Kyra’s mother’s observations did not make a difference to the outcome for Kyra.”

The report said on the day following surgery Kyra began vomiting and her heart rate was elevated. Nursing staff were worried she may have sepsis and treatment was given.

“The nursing staff had significant concerns about Kyra and raised those concerns with medical staff as frequently as they felt able to do. I am satisfied on the basis of the evidence which I have heard, that the nursing staff supporting Kyra raised the concerns as soon as they were able to do so and as regularly as required to safeguard Kyra,” the report concluded.

Deterioration

Ms Combes ruled “on the balance of probabilities, that insufficient weight was placed on the nursing concerns about Kyra.

"The nursing staff were the best placed to identify the overall holistic view of Kyra’s condition and they had significant concerns about her deterioration.”

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Ms Combes said there were also issues over the surgery consent process which meant that Kyra’s parents did not give fully informed consent. This is because the risks were not explained clearly to them.

Kyra’s mother gave evidence that, from what she was told by a consultant, she believed that the surgery was less risky than the procedure to put the stoma in place had been.

However, the coroner accepted that, because this procedure was necessary, the surgery would have taken place anyway with the same outcome for Kyra.

Sheffield Children’s Hospital must now respond to the report by January 30, outlining the action it has or will take – or why it won’t make any changes.