Baby died days after twin brother when hospital staff missed chances to save him

Hospital staff ‘missed opportunities’ to save a premature newborn baby who died just days after his twin brother.

Masen Rushton-Walley died when a vital ventilation tube was dislodged as he was being cared for by nurses.

Masen’s twin Kole, both born prematurely at 28 weeks, had died several days earlier at Saint Mary’s Hospital in Manchester, leaving parents Nicola and Daniel Rushton-Walley, both 30, devastated.

Coroner Sally Hatfield told an inquest at Manchester town hall on Thursday that a delay in recognising the tube had become dislodged had contributed to his death, reports the Manchester Evening News.

The Manchester University NHS Foundation Trust have now apologised for failings in Masen’s care which contributed to his tragic death.

They added that they have ‘taken steps to ensure that lessons have been learnt’.

Four days after his birth on May 5, 2016, Masen was transferred to Saint Mary’s Hospital to undergo surgery to his bowel before being placed on to the hospital’s neonatal intensive care unit.

A ventilation tube was fitted to his lungs due to the prematurity of his birth and subsequent operation, and Masen was reported to have been in a ‘stable’ condition.

His mother had stayed by her son’s side since his arrival at Saint Mary’s, but on the evening of May 12 she was assured by staff on the ward that her son was ‘stable’ and she should get some rest.

Several hours later, she received a phone call from panicked hospital staff telling her to come over ‘immediately’, as Masen had gone into cardiac arrest.

He sadly passed away on the morning of May 13, after his parents made the heartbreaking decision to end resuscitation efforts.

The infant had been transferred from the Royal Stoke Hospital – where he was born – to receive specialist care in Manchester.

The dedicated nurse responsible for Masen, Jordan Washington, told the court that she had ‘no concerns’ in the hours leading up to Masen’s death.

At around 6.30am on the morning of May 13, the nurse said she needed to change Masen’s position from his right to left side, in order to ‘relieve pressure’ – a procedure commonly carried out in premature babies.

The procedure works by briefly disconnecting a section of the breathing tube whilst the baby is moved, before it is reconnected, the court was told.

Nurse Washington said she had been responsible for moving Masen, whilst another nurse – Adele Fitzgerald – assisted to move the tubing.

This was confirmed to be carried out in line with hospital procedure.

Nurse Washington told the court that there is a ‘small risk’ that the tube could become dislodged when carrying out this procedure, but said she believed it had been successful by Masen’s ‘pink’ colour.

It wasn’t until a saturation monitor attached to Masen began to produce alerts that nurse Washington suspected something was wrong.

"The first thing that happened was his saturations reduced and there wasn’t a very good trace on the monitor," she said.

"I thought this was because of the procedure of repositioning."

The nurse went on to say that the ventilator machine then began ‘alarming,’ which she said could be due to excess water in the ventilation tube or because the baby wasn’t breathing.

"I thought it was because of water as the baby still looked fine," she said.

She and nurse Fitzgerald say they repeated the steps and flushed out any excess water, but the ventilation alarm continued to ring.

The court heard that both nurses opted for manual ventilation using a mask and a pump as Masen had begun to turn pale in colour and his chest showed no sign of movement.

An emergency call was made and a number of senior doctors prepared and begun working to resuscitate Masen, but their efforts proved unsuccessful.

Dr Catherine Johnson, a neonatal consultant instructed by the trust, said she believed the tube had become dislodged, but this was not picked up by nurses quickly enough.

She said: "By the time it was recognised it was too far down the line for Masen to have been able to recover from that.

"On balance, had that been done sooner, I think there was a chance that resuscitation would have been successful."

Dr Johnson confirmed that there had been ‘a time when an opportunity to save Masen had been missed’.

Paediatric pathologist Melanie Newbould said Masen had died as a result of ‘an acute collapse in a premature infant caused by a dislodged endotracheal tube’.

The court heard that two options of heart monitoring had been available to nurses but only one was used in Masen’s care.

It is believed that had Mason’s heart rate been monitored by an accompanying ECG lead, nurses may have been able to pick up ‘vital’ information sooner.

Trust representative Dr Anthony Emmerson assured the court that the hospital trust had made changes to procedures following Masen’s death, including implementing a mandatory double monitoring system for babies on the neonatal unit.

Recording a narrative conclusion, assistant coroner Sally Hatfield said: "One cannot wholly avoid the risk of dislodgement but the key is recognition of the problem.

"It is agreed there had been a dislodgement but it had not been appreciated quickly enough and when resuscitation started it was already too late.

"By the time the problem was recognised, Masen had suffered a cardiorespiratory arrest and could not have been revived."

In a statement, Mrs Rushton-Walley said: “We are still coming to terms with losing Masen and Kole, but I hope that if any good can come from our loss, it will be that lessons will be learned and that I can help other families.

“No parents should have to go through what Daniel and I have gone through.

"The pain is excruciating and not a day goes by where I don’t think about how if things had been done differently, Masen would still be with us now.

“We truly hope that more can be done to improve care standards so that other families do not face the nightmare we have been through.”

A spokesman for Manchester University NHS Foundation Trust said: “We wish to offer our sincere condolences and apologies to Masen’s family for the loss of their much loved baby. Our heartfelt sympathies go out to them.

“Following Masen’s death, the Trust undertook an immediate and thorough investigation to examine the care he received.

"This included obtaining independent expert advice from a Consultant Neonatologist. The review identified lapses in standards of care provided to Masen.”

“We wish to reassure our patients and the public that we have taken steps to ensure that lessons have been learnt from this sad incident.

"We have maintained contact with Masen’s family and worked closely with the Coroner’s office to prepare for today’s inquest and will continue to support them during this time.”

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