Four months after her young son stopped breathing, Jessica Webb believes he is still experiencing problems. Health Correspondent Claire Carter reports.
WHEN Steve and Jessica Webb were called to hospital because their son George had stopped breathing there was panic, and then relief that he had been resuscitated.
But the family were then confronted with the revelation that baby George had not been connected to the oxygen supply for 25 minutes while he was being resuscitated – because no one checked a mask in his cot was connected up.
Royal Derby Hospital has apologised to the family of seven-month-old George and says it has changed its training.
But Mrs Webb, 25, is concerned that George has not developed properly since the incident. She said: "I'm absolutely devastated. I've never been so stressed and upset."
George was born prematurely at 28 weeks on July 30 and spent ten weeks in intensive care before going home.
But on November 8, the couple, from Toton, took him back to hospital because he was unwell with a suspected respiratory infection.
The hospital called the parents in the early hours three days later to say that George had stopped breathing.
Mother-of-four Mrs Webb said: "We were put in a room and he had all kinds of tubes sticking out of him and they were still trying to ventilate him. At about noon, they were going to transfer him to the Queen's Medical Centre for a different ventilator.
"About ten minutes before he was due to leave they took us into a room and said they were really sorry but they had forgotten to give him oxygen."
After an investigation, bosses at the Royal Derby admitted the youngster was not connected to oxygen for 25 minutes while being resuscitated.
A mask in his cot was placed near his face and the high-flow oxygen machine turned on – but there was no check to see if it was connected.
A hospital report said while George was being resuscitated, his oxygen saturation levels dropped from 86% to 60% and he turned blue.
It added: "There was a failure to check, when using an ambu bag and mask, that this was connected to the oxygen supply."
The report said the type of bag in the cot was not one staff were familiar with or had used within the hospital.
Concerns were also raised about training. The senior house officer, who was on a placement in the paediatric department, felt she needed more training and booked herself on to the hospital's own paediatric life-support training, though it was not available until the end of her placement.
The anaesthetic registrar, also part of the resuscitation team, had not had paediatric life-support training since 2005.
But the report said all staff had received mandatory resuscitation training.
After the incident, George was transferred to the Queen's Medical Centre and was on a ventilator for nine days and remained in hospital for two weeks.
Mrs Webb said: "I've never had anything happen like this in my life. I can't fault the hospital for neonatal care, but I can't express how angry I am.
"I was absolutely devastated, I didn't know if he would be all right."
She said George has to be fed through a tube and needed physiotherapy after he stopped using the right side of his body. She said she had noticed he also stopped growing for a period of time and she has concerns about his development.
A letter from the QMC after a hospital stay in February said the youngster was "failing to thrive with poor weight gain".
However, it has not been established by doctors whether this was a direct result of the lack of oxygen or other problems. He is still receiving treatment.
The official report into the incident at Derby said the long-term impact on George was unclear, but stated he was at the right developmental stage for his age.
But Mrs Webb said she was concerned his symptoms were down to the incident.
"He was thriving before all this happened," she said.
The report recommended:
An urgent memo be sent to staff telling them to alert the nurse-in-charge if they are unfamiliar with any equipment
An urgent review of the level of training given to medical staff
A check to ensure all nursing staff have basic life-support training
A review of training specifically to ensure staff know their responsibilities for connecting oxygen
All staff to be reminded of the importance of accurate record keeping
Brigid Stacey, director of nursing and midwifery at Derby Hospitals NHS Foundation Trust, said: "We are sorry for the distress this has caused George's family and have kept them informed about the investigation, shared our findings with them and supported them during this difficult time.
"The investigation identified several recommendations for us to put in place to ensure that this kind of incident doesn't happen again. These have been implemented."
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