Hospital chiefs have reviewed procedures after a premature baby suffered a heart attack and died after a feeding tube was wrongly inserted.
Barts Health Trust, which runs Newham University Hospital, said this week that a comprehensive action plan to train neo-natal staff to correctly insert “long lines” had been undertaken to avoid a similar tragedy to that of nine-day-old Ka’leah Noel, whose inquest was held last week.
Ka’leah and her twin brother Kaleem were born on May 7, 2012, at just 27 weeks and six days after their mother, Chanell Miller, went into sudden labour.
Ka’leah was the smaller of the two, weighing less than a kilogram, and was placed in the neonatal baby unit at the hospital, Walthamstow Coroner’s Court heard.
An umbilical venus catheter was initially inserted to feed her, but on May 11 the decision was made to replace it with a long line tube.
Dr Andrew Bright, who inserted the line was in his first year of specialty training.
He said he had made three successful insertions and felt confident to do it without supervision.
He added that he checked the X-ray with a senior member of staff, Dr Elza Samuilova, who said the line looked correct.
However, the thin line was partially obscured and it was not identified that the end of it was in the wrong place.
Miss Miller, who was living in Leighton Avenue, Manor Park at the time, said she saw Dr Bright trying to put the line in.
She said: “I watched him for a little bit and he looked like he was struggling.”
Paediatric pathologist Dr Irene Scheimberg said there were two ways the tube could have ended up in the wrong place, either through being wrongly inserted or through migration.
She gave cardiac tamponade, a “rare but recognised condition” where fluid builds up around the heart, as the cause of death, combined with Ka’leah’s prematurity.
Coroner Dr Shirley Radcliffe recorded a narrative verdict. She said: “I have no doubt that the line was, in fact, incorrectly positioned.”
A spokesman for Bart’s said it had apologised in writing to Miss Miller for the distress caused as a result of the failings in care provided.
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