Baby Teddy is dead, Whats happened? Who is Teddie Mitchell? – death

By | January 3, 2022

A coroner found there were “undoubtedly failings” in the care of a baby who died less than 48 hours after being born.

Laurinda Bower, assistant coroner, said the failings had been accepted by Nottingham University Hospitals NHS Trust (NUH).

Miss Bower said baby Edward Charles Errington Rozkalns’ death was unascertained as she gave a narrative verdict at Nottingham’s Council House today (October 22).

Baby Teddy died at the Queen’s Medical Centre, Nottingham, on November 24, 2020, less than 48 hours after his birth. The cause of death could not be ascertained.

Baby Teddy is dead, Whats happened? Who is Teddie Mitchell? – death – Obituary

The inquest had heard he was born after an induced labour as he was of small-for-gestational-age (SGA).

An independent report found it was not recognised that he needed post-natal hypoglycemia screening.

This was never done but the coroner was not able to determine whether the accepted failures in his post-natal care have “probably or possibly” contributed to his death.

Miss Bower said: “There were undoubtedly failings in Teddy’s care.

“This has been accepted by the trust. The care provided to Teddy failed to comply with local and national guidance, and further, the initial error was not detected despite multiple handovers of care involving multiple autonomous health professionals.

“This is not a simple individual error by a single health care professional, albeit that clearly did occur in this case.

“Nor is it a case of fellow professionals simply failing to detect that error. Again, that undoubtedly occurred here.

“But both the individual failing, and then the multiple missed opportunities to detect this error, contributed to the trust’s failure to have in place a robust system for detecting babies that require screening.”

The inquest heard evidence from Sharon Wallis, the head of midwifery at NUH, that there are no less than 136 pieces of guidance applicable to midwifery care.

The coroner said, indeed, many of the guidelines will not be relevant to the pathway of care that the midwife is providing.

She said: “However, what there does need to be is a safe system in place for triggering the midwife to consider the guidance that is relevant to that patient at that point of care.

“The fact that the system for identifying babies that require blood sugar monitoring rested on the shoulders of a single midwife, without adequate prompts as to the relevant criteria, or a safety net to capture omissions, is a systemic failing.

“Senior leadership is responsible for the systems in place and ensuring that staff are appropriately supported.”

And she said it is the senior leadership team that is also responsible for ensuring clinical guidelines are embedded in practice.

Miss Bower said: “It was worrying to hear that so many midwives, many of whom were of a number of years’ standing in the profession, had a misunderstanding of the criteria for commencing monitoring (for post-natal hypoglycemia) and that this misunderstanding had continued for so long – years in some cases.

“Midwife Cronin said she had been applying the same single, and incorrect, criteria regarding birthweight since 2015. That is five years prior to the error in Teddy’s case.

“The effect of the failure to monitor Teddy appropriately has not just had an impact on the care he received, but has led to an absence of evidence of blood sugar readings in life, which has had a profound impact on my ability to reach a conclusion as to the cause of Teddy’s death”.

The inquest heard Teddy was discharged with his mum, Kim, from hospital.

She noticed his colour was not right after she put him in his cot at home.

His father, Jason, took Teddy off her and he was floppy, the hearing was told.

Errington Rozkalns called 999 and did CPR before Teddy was taken to the Queen’s Medical Centre, Nottingham, with his mother with him in an ambulance.

He arrived in cardiac arrest and, despite efforts to save him, he died.

The main finding of a post-mortem was sudden unexpected neonatal death.

Director of midwifery Sharon Wallis said: “We would like to offer our sincerest condolences to Miss Errington and Mr Rozkalns for the loss of baby Teddy.

“We are truly sorry that we didn’t identify the correct pathway of care for him, and have made significant changes to the way we care for mothers and babies in these circumstances since Teddy’s birth, including introducing mandatory recording fields around birthweight, to ensure that babies receive the appropriate care.”