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28 April 2022
Baby twin’s death contributed to by neglect, inquest finds
A coroner has found that neglect by Bolton Hospital contributed to the death of a baby twin and this would have been prevented if antibiotics had been provided.
Rachael Heyes, a medical negligence solicitor at JMW Solicitors who dealt with the family of Kingsley Olasupo’s legal case, said:
“It has been clear from the start that there were a catalogue of errors in the care Kingsley received, however in reaching his conclusions, the coroner found that neglect by the hospital contributed to his death and this would have been prevented if antibiotics had been provided, which based on the overwhelming evidence obtained, is the only conclusion that could be reached.
“The family has waited more than three years for the inquest into Kingsley’s death to take place and have approached their search for answers with dignity, patience and remarkable strength. Nothing can take away the unimaginable pain that Tunde, Nicola and the whole of the family have suffered as a result of Kingsley’s death but they have now finally had the opportunity to get answers from those directly responsible for his care.
“The root cause of Kingsley’s death was multi-faceted. Kingsley had several risk factors for infection, but despite this, he was not reviewed by a doctor after his birth or at regular intervals afterwards. Midwives also did not complete the appropriate sepsis charts and did not seek prompt advice from doctors. It is therefore clear that there was a lack of implementation of policies and practices in relation to early recognition of infection in premature babies. It is also evident that there was a breakdown of communication between the clinicians and poor record keeping, which resulted in a complete lack of appreciation of Kingsley’s condition, in the context of his twin sister who was well. This resulted in Kingsley not receiving antibiotics when these should have been given and caused him to sadly suffer an unsurvivable brain injury.
“It is now vital that Bolton NHS Foundation Trust, and other trusts, ensure that lessons are learned so that the tragic failures that happened to Kingsley are not repeated again. It is imperative going forward that all maternity trusts ensure that midwives are trained on recognising risk factors for infection and are aware of the need for early review by a doctor if a baby’s condition causes concern at any time. It must also be recognised that at risk babies should have prompt and thorough reviews by doctors to provide the earliest opportunity to administer appropriate treatment.”
Tunde Olasupo, Kingsley and Princess’ father, said: “We want Kingsley to be recognised and remembered as the baby who put new and better policies in place. We want the details of Kingsley’s case to be used in hospitals nationwide to prevent this from happening again. No amount of money in the world can ever replace Kingsley; our only wish is that no one else goes through what we have and are failed the way Kingsley was. We will not stop pushing for changes and one of the things we want to push for is a permanent memorial of Kingsley, to always remind the doctors and midwives that simple mistakes can lead to a catastrophic outcome.”
The four-day inquest into took place at Bolton Coroner’s Court.
Kingsley and his twin sister Princess were born on 8 April 2019 in a good condition. However, they were slightly premature at 35 weeks, there was meconium (baby’s first stool) present when Kingsley was born and he had a low birth weight – all risk factors for infection.
Over the next three days Kingsley’s feeding was poor and his temperature low, which resulted in him being admitted to the special care baby unit on 11 April. On admission, Kingsley had a history of temperature instability and ongoing poor feeding, which was in stark contrast to his twin sister who was feeding well Despite reviews by two doctors, Kingsley was not screened for infection and antibiotics were not commenced.
Kingsley’s condition deteriorated and on 12 April 2019 an infection screen was eventually undertaken. Kingsley was diagnosed with bacterial meningitis and sepsis and antibiotics were started. However, tragically a brain scan carried out on 18 April 2019 revealed severe brain damage which he could not survive. Kingsley’s parents Tunde Olasupo and Nicola Daley, of Bolton, were then informed that there was nothing more the hospital could do for him and doctors would not intervene if he was to get into difficulties with his airways, such as a blockage. This meant that if they wished for Kingsley to die peacefully, they would have to agree to remove his life support leaving them no choice but to do so. Kingsley passed away at 11.15pm on 18 April 2019.
Tunde and Nicola believed something had gone badly wrong with Kingsley’s care and challenged Bolton NHS Foundation Trust with the help of JMW’s Rachael Heyes. Rachael’s investigation found that if Kingsley had been treated with antibiotics on admission to the neonatal ward, he would have survived. After these allegations were made, the trust accepted liability in full in October 2021 and admitted that if antibiotics had been provided in a timely manner, Kingsley would not have died. An official apology followed in March 2022 and an undisclosed compensation amount. However, the case has never been about money for the family, who have been torn apart by Kingsley’s death; their priority was to ensure that a full independent investigation was undertaken into the care Kingsley received and lessons were learnt following the serious errors made. Bolton NHS Foundation Trust’s own internal investigation identified a catalogue of serious problems with the care provided to Kingsley.
Failings in care identified in the report include:
Kingsley was not referred to a neonatologist after birth
- A sepsis tool was not used on day one of Kingsley’s life despite several red flags being present – had this been done he would have been given antibiotics
- Delay in the taking of bloods and late recognition of sepsis
- No daily neonatal reviews and lack of appropriate escalation
- No physical medical review of baby when concerns were first escalated by midwives to the neonatal team.
- Delay in further escalation when baby continued with poor feeding
- Incomplete neonatal reviews
- Inaccurate and misleading documentation
- Multiple observation charts for babies some of which contradict each other
- Ineffective completion of assessment of baby well-being undertaken on the postnatal ward.
- Inadequate recording of observations
- Poor documentation of newborn rash
- Poor communication / lack of handover
- No consideration of the reason for poor feeding in the context of a well feeding twin.
Please direct all media enquiries to Kelly Hindle on the details below.
Hospital investigation report, admission of negligence and apology available on request
For more information or to arrange an interview, please contact Kelly Hindle or Samantha Meakin on the details below:
D. 0161 828 1868
D: 0161 828 1981
Note to Editors
JMW Solicitors LLP is a leading Manchester law firm and offers a broad range of legal services to both commercial and private clients.
JMW’s Clinical Negligence team is headed up by leading clinical negligence lawyer, Eddie Jones.