HM Senior Coroner for Suffolk, Dr Peter Dean, will 'open' the inquest at a short hearing on May 23 2018 which will determine the scope of the inquest and what witness and expert evidence will be obtained.
Riyad was born by vaginal delivery at 3:19 pm on 15 July 2005. His Apgar score (the test used to check a baby's health) was poor and the infant was slow to respond to stimulus, slightly floppy and blue. He was taken to resuscitation and while his Apgar score improved he was noted to be grunting and hypothermic. His blood sugars were low and he was taken to the antenatal unit.
His mother, Bilkis Ali, visited her son over the course of the next 24 hours and received reassurance, although it was evident from the medical notes that Riyad was in fact deteriorating. At 5:00 pm the following day, Mrs Ali was told that her son was very sick and medical staff were doing all they could to save him. Cardiac massage commenced but resuscitation was discontinued at 5:25 pm and Riyad’s ventilator was turned off 20 minutes later.
Mrs Ali was advised by doctors at the time that the likely cause of her son’s death was genetic and a post-mortem was not necessary. She accepted that, believing that the cause of death was indeed due to hereditary factors.
When she was having her third child (who is perfectly fit and healthy as are her other children) Mrs Ali was asked to complete an ante-natal form about previous pregnancies. She became very upset and distressed when completing the section detailing problems with previous pregnancies.
Her midwife suggested that she request her medical files in relation to Riyad’s birth. It was only then that she discovered that the content of the medical notes and records were not in line with what she had been told at the time and that there had been an investigation into the cause of Riyad’s death, about which she had not been informed or consulted.
The case was reported to the Coroner and following a report from a neonatologist the Coroner agreed to open an inquest and also ordered that there should be genetic testing on Riyad’s retained cells.
The family is represented at inquest by Shoosmiths Sue Prior, who commented:
‘From the information which has now come to light, it seems clear that there were significant failings in care and a lack of appropriate medical record keeping. There were numerous early opportunities for a paediatrician to be called but there were significant delays in doing so.’
‘Whilst the “duty of candour” has only been enshrined in law in recent years, it is deeply concerning that the findings of a serious untoward incident report were not shared with the family and that the parents were left to believe that the only possibility for the cause of their baby’s death was through genetic or metabolic issues, for which they have blamed themselves. The family hope a full inquest will give them clarity and answers to the many questions they have about what did cause Riyad’s death.’
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