A baby who was not given vitamin K at birth died as a result of “a gross failure in medical care amounting to neglect”, a coroner has found.
Like all premature babies born at the Rosie Hospital in Cambridge, William was transferred to the neonatal unit at Addenbrooke’s following his birth in July 2020. He made good progress and was discharged after about two weeks.
A note made by a doctor upon his admission to the neonatal unit had erroneously stated that William had received vitamin K when he had not.
That error was thereafter repeated or ‘pulled through’ to other records, including his discharge summary. The true position was never checked by looking at William’s ‘MAR’ (medicines administration record). The Coroner found that a ‘First Hour of Care Checklist’ had not been completed. This would have prompted clinicians to provide vitamin K.
Vitamin K is given routinely to babies following birth. Its role is to make the clotting factors that babies – especially premature babies – lack so that the blood clots should a bleed occur. The Court also heard that vitamin K “virtually eliminates” the risk of the potentially fatal condition of vitamin K-deficiency bleeding (VKDB).
William’s mother, Dr Naomi Moris, had made stated several times that she wanted him to have vitamin K. It was in her birth plan, which she said no one looked at.
William’s father, Dr Alex Patto, also recalled asking a neonatal doctor whether the baby had received the drug. He recalled the doctor confirming that he had done so.
In September 2020, William became ill and was found to have suffered a severe bleed on his brain, causing irreversible damage in an otherwise healthy baby. A consultant haematologist’s first consideration was whether William had received Vitamin K at birth; the supplement is routine, and helps make clotting factors that, virtually eliminating the risk of Vitamin-K deficient bleeding (VKDB), also known as haemorrhagic disease of the newborn (HDB). A review of the neonatal admission records suggested that he had, but the error later became apparent.
Assistant Coroner Lorna Skinner KC considered evidence from William’s parents, Dr Naomi Moris and Dr Alex Patto, as well as from numerous clinicians.
She accepted the invitation to include in her narrative conclusion a rider of neglect on the basis that the failure to provide vitamin K was a gross failure to provide basic medical attention to someone in a dependent position, and that it caused William’s death.
The Coroner found that “William died of natural causes – a vitamin K deficiency that caused a spontaneous intracranial haemorrhage.”
She concluded that William’s death “was contributed to by neglect in that he was not given vitamin K after birth and if he had been, he would not have died.”
Cambridge University Hospitals NHS Foundation Trust has apologised and fully accepted the Coroner’s findings.