Jasmine Leng represented the parents of 35-day-old Teddy Martin at a week-long inquest in Nottingham Coroner’s Court. The Coroner concluded that Teddy’s death had been preventable.
Teddy was born with Beckwith-Wiedemann Syndrome, a genetic ‘overgrowth’ condition meaning that he had a larger-than-average tongue (called ‘macroglossia’). In the weeks before his death, Teddy began to have increased difficulties maintaining his own airway which required him to be orally intubated. It was decided that it would be safer for Teddy to be intubated nasally and a procedure was planned for 5th September 2022 to change his oral endotracheal tube to a nasal tube. Sadly the procedure failed when the nasal tube was accidentally dislodged. The ‘rescue plan’ to rely on facemask ventilation if intubation failed was insufficient to manage Teddy’s rapid deterioration. He died despite significant attempts at resuscitation.
The Trust conducted a Patient Safety Incident Investigation which concluded that Teddy had a ‘difficult airway’ and that the clinicians conducting the tube change had not appreciated that such a procedure would be high risk for Teddy. After publication of the report to the family it was revealed that the report was not agreed (as the family had been told) as multiple members of the treating team disagreed with its conclusions. Those clinicians who disagreed with the investigation report were given Interested Person status and represented at the inquest.
At inquest, the Coroner criticised the Trust’s investigation which was described as a “disaster”. The inquest highlighted deficiencies in the investigation process, including problems securing statements from clinicians about what happened and failures to minute important investigative meetings. The Trust’s duty of candour also came under scrutiny.
The Coroner gave a narrative conclusion which identified causative failures to formally identify Teddy as a patient with a ‘difficult airway’ (as per the Trust’s guidance); failures to conduct an appropriate risk assessment and failures to have a paediatric anaesthetist on standby.
The Trust have admitted liability for Teddy’s death.
Jasmine was instructed by Bethany Kyle of Ashtons Legal.
You can read more about the case here.
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