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21 April 2022
Inquest for baby who died of infection after maternity staff failed to give antibiotics
A five-day inquest into the death of a 10-day old baby who died following a catalogue of failings by maternity services at Bolton Hospital opens on 25 April 2022 at Bolton Coroner’s Court.
Kingsley Olasupo 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 Rachael Heyes, a solicitor specialising in medical negligence at JMW. 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. A statement will be provided following the inquest conclusion.
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.