Baby shaken to death 'could have been saved' by hospital

It said there was a 'significant probability' that 16 month-old Kyle Keen, who had been admitted to Walsall Manor, would not have died if action had been taken to intervene.

The youngster died in June 2006 following his transfer from Walsall Manor Hospital to the paediatric intensive care unit in Stoke when a bleed on the brain was diagnosed.

He had been admitted a few days previously to Walsall Manor on June 21, 2006, where bruises were noted but no follow-up action was taken and he was discharged.

The toddler, from Walsall, was then admitted to the hospital off Pleck Road again on June 29 with a brain injury and died a day later.

Kyle had been shaken by his stepfather Tyrone Matthews, then aged 25, who was sentenced to six-and-a-half years in prison for manslaughter.

An independent report which was carried out by consultants Cordis Bright and was released today has revealed:

*There were serious errors of judgement that may have led directly to further injury to Kyle after his admission on June 21

*Staff who raised concerns should have pursued those further, even though a senior colleague disagreed

*Record keeping at the time was poor, inadequate and contained numerous omissions.

*The trust did not take appropriate action at the time to investigate thoroughly

The hospital today apologised and insisted improvements have been made, including how it works with the Walsall Local Safeguarding Children Board and Walsall Council children's services.

The trust said it should have also shared information with natural father Robert Keen who has been seeking answers.

Officials also said there are now new processes for ensuring that the information for a child is available in the medical records in the event of the same youngster being admitted.

See also:

• Baby killer is locked up

• Hospital under fire over tragedy

• Fresh inquiry ordered over death of baby Kyle

• Father hopes for the truth about tragic Kyle Keen

• Whistleblower's book lifts lid on fight against Walsall Manor Hospital chiefs

Richard Kirby, chief executive at Walsall Healthcare NHS Trust, who was not in charge at the time, added: "We recognise that an apology alone is not sufficient and I hope that we have been able to demonstrate to Mr Keen our commitment to act on what we have learnt from this review."

Dr David Drew was the head of the paediatric department at Manor Hospital at the time. He later claimed he acted as a whistleblower in the case of the toddler and had tried to raise concerns over his death and a member of staff in the department.

However he was later sacked in 2010 for gross misconduct and insubordination for failing to accept review instructions and disclosing confidential information, in relation to other matters.

He said today that a number of medical staff had told a consultant who had seen Kyle that the case needed to be referred to social services.

He said: "From day one it was quite clear an opportunity had been missed the previous week and this little boy had suspicious, unexplained bruising."

He said he had no doubt that if Kyle had been referred to social services he would have survived.

The father of Kyle Keen today said he hopes lessons have been learned as his son would 'probably still be alive' if cared for properly by a hospital.

Robert Keen has been waiting years for answers following the death of his 16 month-old son in June 2006.

Mr Keen made a formal complaint about the inadequate care the youngster received and chief executive Richard Kirby agreed to commission the review.

Mr Keen said: "The circumstances of his death were shocking at the time.

"In 2012 I learned from a senior doctor who had helped look after Kyle in his final hours that he died following 'catastrophic mistakes' in basic safeguarding at Manor Hospital.

"The hospital did not tell me anything about this.

"I have learned from the report that if the hospital had cared for Kyle properly he would probably still be alive.

"It is impossible for me to say how this makes me feel.

"It is all made worse by the fact that this has been kept from us for eight long years.

"I understand from the report that Kyle was sent home where he met his death by a doctor against the advice of medical and nursing colleagues and against the child protection policy.

"He should have been referred to social services. This would probably have saved his life.

"The report is also clear that Kyle's death was not investigated properly at the time or subsequently.

"Senior management at the hospital failed to ensure that the reason Kyle was sent home to his death was understood and that the lessons were learned.

"Factors which may have contributed to the decision to send Kyle home are only now being addressed. It is good to learn the truth at last. But the report leaves many questions in my mind unanswered.

"The review has been unable to find out why I was not involved in the investigations into Kyle's death.

"Nor why neither the hospital nor safeguarding board contacted me to tell me of their findings.

"It seems that this is a mystery. Other questions remain unanswered.

"I hope that Manor Hospital will learn the lessons from this latest investigation and that no other Walsall family will lose a child because of such serious mistakes.

"But if that does happen I hope the hospital will immediately put its hands up and admit it got it wrong. Covering things up for years only makes things worse."

The hospital was criticised in a serious case review in 2009 after it emerged nurses treating Kyle for a stomach upset had spotted suspicious bruises on his body a week before he was admitted with the brain injury.

Their concerns were not reported to social services at the time by the hospital.

Tyrone Matthews, then aged 25, denied murder but admitted the lesser charge of manslaughter at Wolverhampton Crown Court and was jailed in 2007. Kyle's mother Kerry McIntosh, then aged 21, of Hatherton Street, Butts, admitted cruelty by neglect and was given a six-month suspended prison term. The trust said it should have also shared information with natural father Robert Keen who has been seeking answers. There are now new processes for ensuring that the information for a child is available in the medical records in the event of the same youngster being admitted.

Work is taking place to improve the quality of clinical record keeping, which was a recognised in a recent Care Quality Commission inspection.