The official Ockenden inquiry is investigating more than the originally planned cases, after claims that as many as 60 other cases of infant and maternal deaths and severely injured babies merited further examination, according to a recent report in the Health Service Journal.
Ockenden was commissioned in April 2017 by the then Health Secretary Jeremy Hunt to look into the deaths of 23 babies and mothers, allegedly as a result of poor care, at Shrewsbury and Telford Hospital NHS Trust. Maternity care at the Trust in recent years has been the subject of no fewer than six separate inquiries, including one by the Royal College of Obstetricians and Gynaecologists.
The Trust itself has been undertaking what is called a ‘legacy review’ into historical cases. One of these cases under investigation is that of our client Mrs Kumari, whose daughter Rushi is alleged to have suffered severe brain damage due to the incorrect insertion and leakage of infant formula from a Total Parenteral Nutrition (TPN) tube (a method of feeding that bypasses the gastrointestinal tract and introduces fluids through a vein).
Rushi was born prematurely in June 2014 at the Royal Shrewsbury Hospital via caesarean section. Her birth weight was extremely low, hence the use of the TPN tube, but an issue with the positioning of the line was identified as Rushi's condition deteriorated.
The family believe the formula had been leaking into the infant’s cerebro-spinal fluid unnoticed for several hours. Rushi experienced seizures and antibiotics were administered to treat suspected chemical meningitis caused by the TPN leak. Cranial ultrasound showed some abnormality and cerebrospinal fluid analysis was consistent with such a TPN leak.
Rushi was discharged in early September 2014. Her growth and development is significantly delayed: she has a special pushchair, a walker and Zimmer frame because she cannot walk long distances and struggles to communicate verbally.
The family had several inconclusive meetings with the hospital but no formal hospital investigation had been carried out to the family’s knowledge until recently, when the family were contacted for their consent to be part of the Trust’s internal legacy review of Rushi’s care, being assured that the Trust was ‘determined to learn from these reviews and committed to making improvements rapidly where we need to do so.’
The family gave their consent to the investigation but to date have heard nothing further from the Trust.
This case is at a very early stage and it is not yet known what impact the TPN leak has had on Rushi's condition and prognosis.
Commenting on the case, Kishma Bolaji, an associate solicitor in the Shoosmiths medical negligence team, said:
‘Rushi requires constant care and attention due to her difficulties and the family have been given very little guidance and understanding of Rushi’s condition, her prognosis and likely future needs. While we continue to investigate the circumstances of the case and any possible claim and give the family as much support as we can, it’s clear from Mrs Kumari’s experience that the cases being investigated by Ockenden and those subject to the internal clinical review are a matter of great concern for patient care.’
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