Cassian Curry inquest: Sheffield hospital 'neglect' contributed to death of premature two-day-old baby

Hospital failings and ‘neglect’ contributed to the death of a premature two-day-old Sheffield baby in a neonatal unit, a coroner has found.

By Katie Dickinson, PA
Friday, 22nd April 2022, 5:45 pm

Cassian Curry was born in Sheffield Teaching Hospitals' Jessop Wing maternity unit on April 3 last year, at 28 weeks and ‘very small, even for his age’ at 1lb 10oz (750g).

An inquest at Sheffield Coroner’s Court has heard how Cassian deteriorated rapidly on April 5 and died from a cardiac tamponade, which is when fluid builds up in the space around the heart, eventually preventing it from pumping.

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Karolina Curry and James Curry on their wedding day. Cassian Curry was their 'miracle' baby after many unsuccessful attempts. Picture by Karolina Curry and James Curry

On Friday, assistant coroner Abigail Combes concluded that a failure to record and share information about Cassian's care contributed to his death.

The hearing was told this week how an umbilical venous catheter inserted into Cassian's abdomen to help him feed was in a ‘suboptimal’ position near his heart when it was inserted by two junior doctors.

Neonatal consultant Dr Elizabeth Pilling told the inquest she had intended to have it repositioned within 24 hours, but waited because of the dangers of repeatedly handling a baby as premature as Cassian.

Cassian Curry. See SWNS story SWLEtot. A couple whose “miracle” IVF baby passed away two days after his birth has revealed their heartbreak - as their hospital accepts he died due to “human error”. James and Karolina Curry welcomed their son Cassian into the world in early April last year - after they suffered five previous failed or miscarried pregnancies. But tragedy struck when the “small but strong” tot, weighing 1lb 10oz, died only a few days later, leaving the couple “struggling” to come to terms with their grief. At an inquest into her death at Sheffield Coroner's Court, Karolina said that Cassian’s birth was a “miracle” after her husband was diagnosed with testicular cancer.

Dr Pilling said she had no explanation as to why she then forgot to make sure his feeding line was moved.

Giving her conclusion, Ms Combes said the decision to pause the procedure and reassess it in 24 hours was ‘reasonable and appropriate’, but was ‘not adequately recorded and communicated’ in Cassian's notes, or on the ward round.

The plan should have been recorded on Cassian's ‘pink sheet’, she said, and communicated to his parents.

Ms Combes said this amounted to a ‘gross failure’ in Cassian's care, which contributed to his death.

Cassian Curry. See SWNS story SWLEtot. A couple whose “miracle” IVF baby passed away two days after his birth has revealed their heartbreak - as their hospital accepts he died due to “human error”. James and Karolina Curry welcomed their son Cassian into the world in early April last year - after they suffered five previous failed or miscarried pregnancies. But tragedy struck when the “small but strong” tot, weighing 1lb 10oz, died only a few days later, leaving the couple “struggling” to come to terms with their grief. At an inquest into her death at Sheffield Coroner's Court, Karolina said that Cassian’s birth was a “miracle” after her husband was diagnosed with testicular cancer.

She added: "But for this incident, Cassian would not have died of what he died of, when he died."

The coroner recorded a narrative conclusion, which said Cassian's death was ‘contributed to by neglect’.

In a statement at the start of the hearing, Cassian's mother, Karolina Curry, said she and her husband James had a number of questions about her son's treatment, including reports that the unit was understaffed due to it being the Easter weekend.

But Ms Combes concluded: "There were no systemic failures in the form of staffing issues which caused or contributed to Cassian's death."

Cassian Curry died at Sheffield Teaching Hospitals' Jessop Wing neonatal unit on 5 April 2021.

She said the staffing levels were above the national requirement that weekend, and although there were a number of junior staff present, they were ‘appropriately qualified and able to support the unit adequately’.

The medical director of Sheffield Teaching Hospitals NHS Foundation Trust, Dr Jennifer Hill, has said the trust is ‘so very sorry for what happened’ to Cassian, admitting there was ‘human error in terms of the management of Cassian's umbilical venous catheter’.

Following the inquest, Dr Hill said there had been a full review, changes had already been made and it would take on board any further recommendations from the coroner.

She said: "This was a very rare incident to have happened and everyone involved in his care is devastated.

"There has been a full review of what happened, and changes have already been made to limit the chances of this happening again including additional consultant support at weekends and ongoing improvements to the documentation used.

"We will also be taking on board any further recommendations from the coroner and ensuring we respond with appropriate actions."

James and Karolina with Cassian Curry, who died aged just two days. A coroner has concluded that 'neglect' by Sheffield Teaching Hospitals contributed to his death (pic: Curry Family / Scala / SWNS)

Mr and Mrs Curry have said Cassian was ‘a miracle for us’ when they found out he was on his way after six cycles of IVF.

Following the conclusion, the boy's parents said: "Cassian was a beacon of light and our hearts blossomed under his pure and innocent love.

"He was everything that we dreamed of.

"Today, the coroner concluded that he died because of neglect, and had it not been for the gross failings of those in charge of his care, he would still be with us today.

"Cassian was a true miracle, and we will love and miss him forever."

Fay Marshall, a solicitor at Switalskis Solicitors, who represented the family at the inquest, said: “While the trust has made changes in the last year the coroner did not think they

went far enough, and she will be issuing a prevention of future deaths report.

“James and Karolina have sat patiently and listened to the evidence this week and they do have some answers, but nothing can bring Cassian back. Nothing can lighten their grief over what happened and how it happened.

“Cassian’s death was avoidable. He was a strong baby who should have gone home with his parents who had tried for years to start their family.

“James and Karolina want to make sure the trust makes changes so that no other family has to go through this.”