James Weston represented the family of Leo Silvester, who died at the age of four days as a result of severe brain damage following medical complications at two hospitals. The Inquest at Southwark Coroner’s court heard that Leo’s mother, whilst pregnant, had suffered a stroke as a result of a catheter wrongly being inserted into her artery during surgery at Maidstone hospital. Following transfer to St Thomas’s hospital in London and further surgery for her vascular complications the next day, Leo was born prematurely at 26 weeks gestation. In light of his mother’s communication difficulties following her stroke, she was unable to communicate her labour or Leo’s delivery. Leo was eventually found by nurses on the intensive care unit but resuscitation was delayed for 23 minutes after the consultant wrongly presumed that Leo had been stillborn.

The Coroner, Andrew Harris, concluded that Leo died of hypoxic ischaemic encephalopathy caused by sepsis, complications of maternal surgery and a delay in resuscitation after birth. Following the submissions of the family he ruled that the failure to either examine Leo when first discovered, or to call for emergency paediatric intervention, amounted to coronial neglect.


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