Newborn baby boy died after 'gross failure' at Walsall Manor Hospital

Tommi-Ray Vigrass was born prematurely by emergency caesarean at the Manor Hospital on January 9, Black Country Coroner's Court was told.

Weighing just over a kilogram, Tommi was born with respiration problems and needed ventilation support.

However, the inquest heard how an experienced registrar decided to remove the tube without speaking to other consultants.

He did this after a leak occurred on the ventilation machine, inserting a larger tube.

Baby Tommi was transferred to New Cross Hospital on January 10 and died three days later.

The inquest heard he died of hypoxic brain injury due to difficulties in inserting the tube.

Senior Coroner Zafar Siddique concluded there had been neglect on the trust's part.

Speaking at the second day of the inquest,Mr Siddique said: "On January 9, baby Tommi was born at Walsall Manor Hospital and needed ventilation support.

"Throughout the night there was a leak on the ventilation machine and the registrar took the decision to re-intubate without taking further consultation.

"Several attempts on inserting the tube resulted in oxygen declining rapidly and he was then transferred to New Cross Hospital.

"The doctor had admitted in his statement that it was a 'mistake' to remove the tube overnight before speaking to a senior consultant.

"Taken as a whole, this was a gross failure in medical care. I believe that baby Tommi died due to developing the injuries due to difficulty in inserting the tube and this is neglect.

"I understand that the trust has taken measures following the incident but I will also be writing to them myself.

"I offer my heartfelt condolences to the family for such a terrible time."

Throughout the inquest, statements and evidence were given by doctors and nurses from the trust.

A number of concerns were raised by trust representatives, including the individual failure in clinical decision making by the registrar.

Distraught mother-of-four, Cheryl Frankham, aged 32, of Catches Drive, Bloxwich, said it had left her completely heartbroken.

The full-time mother, who has three daughters, aged three, five and seven, and a 14-year-old son, could not wait to welcome baby Tommi into the world, along with her partner Gareth Vigrass.

Miss Frankham said: "If I had to leave with an accidental death verdict then I wouldn't have been able to live with it.

"The neglect verdict tells me that what they did was wrong and that they know it.

"The coroner has been very switched on and knew what was right.

"Mothers instinct told me that they were to blame.

"There is slight relief at the outcome but it still doesn't take away what has happened."

It was neglect and the wrong decisions made. My young children don't understand, I went to the hospital the other day and my three-year-old asked what I was crying for. It is absolutely heart-breaking."

Bosses at Walsall Healthcare NHS Trust said action had been taken to address issues following an investigation.

Rachel Overfield, director of nursing at the NHS Trust, said: "Firstly, and most importantly, we would like to extend our sympathies to Tommi-Ray's family and apologise once again that our care in this case was not of the standard that our patients and their families expect and deserve.

"The trust's thorough investigation into the decisions made and actions taken that evening identified a number of issues over the standard of care that Tommi-Ray received. These include the procedures followed when changing the baby's breathing tube and the timing of this course of action.

"We have since taken action to ensure that breathing tubes are not changed at night without a consultant paediatrician.

"We have undertaken resuscitation simulation training with staff and put in new processes to ensure equipment is used appropriately during a resuscitation.

"We will be further strengthening these actions immediately.

"We will respond to the coroner's observations in a timely manner and take any further action that may be necessary to strengthen the safety of our services."