An inquest has concluded that a twin baby who died of a bacterial infection would have survived if not for “a gross failure to provide basic medical care” at the Royal Boston Hospital.
Twins Kingsley and Princess Olasupo were born prematurely at 35 weeks, to Tunde Olasupo and Nicola Daley, on 8 April 2019. Kingsley died 10 days later of multiple organ failures caused by bacterial meningitis and sepsis.
The area coroner concluded on 29 April 2022 that Kingsley would have survived had he been assessed for infection in accordance with applicable guidelines and put on appropriate antibiotics earlier.
The Bolton hospital said they are “truly sorry” and “fully accept the outcome of the inquest,” admitting that their care “fell below the standards that Kingsley, Nicola, and Tunde deserved.”
Baby Kingsley and the “Failure to Provide Basic Care”
Unlike his sister, Kingsley had a low temperature, a low birth weight of 2.02 kg, and was not feeding well. The inquest heard that there was meconium (newborn’s first stool) during delivery. All these factors are considered infection risks that should have prompted appropriate action.
A week later, Kingsley’s parents were informed that their baby boy had developed brain damage and multiple organ failure, which he could not survive. They agreed to remove his life support, and Kingsley died on 18 April 2019.
During the inquest it was found that:
- Midwives initially found meconium in his amniotic fluid; however, this was not recorded correctly.
- A senior neonatal practitioner, who checked Kingsley within two minutes of birth, wrongly recorded there had been no meconium and did not escalate him for review by a doctor.
- Details such as heart and respiratory rates were not recorded.
- The baby was not reviewed at regular times following birth.
- Kingsley was examined by a doctor four days after birth and screened for an infection.
- It took over 24 hours before the baby was diagnosed with meningitis due to Enterobacter cloacae and started on appropriate antibiotics.
- Midwives did not complete appropriate sepsis charts and did not seek advice quickly enough from doctors.
- By 13 April, the coroner found the infection was too far advanced and it was too late to treat him.
The ruling found Kingsley:
- Should have been assessed by a paediatric doctor within two hours of his birth and every day thereafter.
- It added that if a doctor had seen and assessed him from birth, in accordance with guidelines, they would have screened him for infection and given antibiotics within 24 hours.
The conclusion
Area coroner Peter Sigee outlined his findings from the inquest on 29 April 2022. He concluded that medical negligence contributed to Kingsley’s death.
Mr Sigee said:
“If a doctor had seen and assessed Kingsley at any time from birth in accordance with the guidelines, then Kingsley …………………….. would have survived. There were individual and systemic failures in the postnatal care of Kingsley, which meant that Kingsley was not assessed and treated for infection in accordance with applicable guidelines…..Taken both individually and together, these amounted to a gross failure to provide basic medical care to Kingsley, and they were causative of his death.”
Newborn Early Warning System
The inquiry heard that the Newborn Early Warning System, which would have helped identify a need for tests, was not generally in use at the time. A midwife said she raised her concerns with the paediatrician but was directed to “warm him up” with a sleep suit.
Another midwife said: “I felt they should have come and checked the baby over…I just felt if you have a concern and it’s raised with a paediatrician, it should be acknowledged and acted upon.”
Implementation of “Significant Changes”
Francis Andrews, medical director at the Trust, said: “On behalf of the Trust, I would like to offer my sincere condolences to Nicola and Tunde for the tragic loss of their little boy, Kingsley…We fully accept the outcome of the inquest and are truly sorry that our care fell below the standards that Kingsley, Nicola and Tunde deserved…We undertook a thorough and transparent investigation, and have reviewed our practices and have made significant changes…Babies who are at high risk of infection on our postnatal ward are monitored more closely by the right specialists in order to better detect early infection….We will continue to do all we can to prevent such a tragedy happening again.”
After Kingsley’s death, the National Institute for Health and Care Excellence, the British Association of Perinatal Medicine, Bolton NHS Foundation Trust, and other partners created and distributed new guidance to better address the risk of neonatal infection.
Tunde Olasupo said: “We want Kingsley to be recognised and remembered as the baby who put new and better policies in place.”
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