A baby girl from Blackburn has died in hospital after missing opportunities to spot complications

A coroner has highlighted how a 14-week-old baby girl died following missed opportunities to anticipate complications after certain medical details were not fully reported.

An inquest at Accrington Town Hall heard how Elsie-Lynn Ganley was born prematurely at 26 weeks on November 26, 2020 in the Neonatal Intensive Care Unit at Burnley General Hospital.

The court heard how his mother, Karen Hogg, from Blackburn, had previously suffered a miscarriage and that there were other complications, but it was not reported.

At nineteen weeks pregnant, Ms Hogg went to the early pregnancy unit and the examination showed that her waters had broken, with a reduced amount of fluid around the baby, which was a ruptured membrane .

Mr Martin Maher, consultant obstetrician at East Lancashire Hospitals NHS Trust, told the inquest this was essential for the baby, as if the water was not there there would have been a high risk of the baby having underdeveloped lungs.

He said as the baby’s mother wanted to continue the pregnancy, it was decided to monitor fetal lung growth complications with the aim of trying to deliver the baby at 37 weeks.

However, further scans showed lack of water due to rupture of the membrane, with antibiotics being prescribed but no signs of infection.

At 21 weeks pregnant, it was found that there was no fluid around the baby, but the baby was developing normally and it was planned to continue to monitor the situation for signs of infection.

However, at 24 weeks, it was found that although the baby’s growth was appropriate, his heart felt large in his chest, which likely meant that his lungs were underdeveloped.

A few weeks later, Miss Hogg presented to the Emergency Assessment Unit with a water leak, and the decision was made to admit her, but there was no evidence of preterm labor .

Miss Hogg was treated and discharged a few days later, but when she began to report contractions she was readmitted to hospital the following day and moved to the central birthing room, where tests showed her baby was breathing.

The neonatal team was present, in anticipation of the birth of a very premature baby, and the baby would have been in a breech position, so it was decided to deliver her as soon as possible.

Elsie was transferred to the neonatal unit, where she was intubated for six minutes. She died on March 10, 2021.

Mr Maher said the complications and a previous miscarriage had not been reported, meaning further steps including taking medication earlier and a referral to prevent premature delivery would have been taken if they had been.

The doctor said it was two missed opportunities, adding: ‘There might have been an opportunity for us if she had gone to the preemie clinic and had premature ultrasounds.’

He said medical staff did not have access to all the information.

Area coroner Richard Taylor pointed out how the rupture of the membrane had occurred seven weeks before delivery, but missed opportunities meant sightings had not happened as they would have if all the information had been fully available.

The coroner said: ‘You could have known there were placenta issues and there had been a 19 week miscarriage.

He added: “Logically, you’d think someone would have spotted it.”

He said it must have been “frustrating” for Mr Maher, adding: “You were operating with one hand tied behind your back.”

The doctor added: “Yes, we would have liked that information.”

The coroner said: ‘The fact that the full obstetrical history of a previous miscarriage was not acknowledged or listened to meant that observations which should have been made had it been acknowledged were not made, and the Potential breakup issues could have been appreciated and depending on what caused the breakup, an opportunity to deal with it was missed.

“All these causes of death are in themselves natural causes due to extreme prematurity. However, something may have been done to prevent the breakup.

“He could have been known about the placenta issues and the 19 week miscarriage – that would have alerted you.”

Recording a narrative conclusion, the coroner said Elsie died at Burnley General Hospital on March 10, 2021, from complications of prematurity following a ruptured membrane for which an opportunity to anticipate was missed following a complete unrecognized obstetrical history.

He said: “It is possible that the rupture of the membrane could have been anticipated – not treated, but anticipated.”

He told his parents: “We cannot say that your daughter’s life would have been saved. We can’t say that because it’s impossible to say how the rupture actually happened, but as the treating clinician, the doctor would have liked to know.

Elsie’s father, Liam Ganley, told the court: ‘I kept saying there was something they could do. To hear you say that now is very hard to hear.

“What if everything that could have been done had been done? Now I know something could have been done, if it would have made a difference no one can say, but that’s what hurts the most.

The doctor said a multi-disciplinary review meeting was held following the case and there had previously been a heavy reliance on paper-based systems, but things had changed significantly with the introduction of a new computer system that automatically gave access to all medical details. He said the new system was fail-safe, adding that he had been instilled in medical staff to review things.

Mr Maher said: ‘Once a midwife has seen a woman, she has access to previous notes and high-risk factors.’

He added: “It will be instilled in our medical staff that things need to be reviewed and clarifications need to be sought.”

Recording a narrative conclusion, Coroner Richard Taylor said Elsie died at Burnley General Hospital on March 10, 2021, from complications of prematurity following a ruptured membrane for which an opportunity to anticipate was missed. , following an unrecognized complete obstetrical history.

Chris Pearson, chief nurse at East Lancashire Hospitals NHS Trust, told LancsLive: ‘I was very sorry to hear of Elsie’s sad passing and would like to extend my heartfelt condolences to her family. Losing a baby under any circumstances is devastating and if we can help the family in any way with their grief, we will. Our colleagues work tirelessly to provide safe, personalized and effective care to our patients. When the outcome is not what we expected or hoped for, we act as quickly as possible to learn lessons and determine how we can prevent it from happening again in the future.

A family friend has created a Go Fund me page for Elsie’s family which can be viewed here.

Download the LancsLive app for free at iPhone here and Android here.

To stay informed, follow LancsLive on Facebook and @LiveLancs on Twitter.

Do you have any news for us? Contact our press office at [email protected].

Get all the latest news, sport and stories delivered to your inbox daily with the LancsLive newsletter here.

About Jerry Richter

Check Also

No private sale, use of fireworks during drought disaster declaration in effect: Bell County judge

BELTON, Texas (KWTX) – Bell County Judge David Blackburn on Wednesday, June 22, issued an …