Baby’s sepsis death a ‘warning’ to other parents
The anguished parents of a baby who died after 17 attempts to insert an IV line in his tiny body - while he was kept naked for hours in a hospital emergency department - say they wished they had spoken up when they "witnessed that something is not quite right".
"Our message as parents is that we are more than responsible for the life of our children," Jorge Franco, the father of baby Esteban, said.
"We cannot just assume that because our child is taken to a prestigious hospital, the medical staff is in control of the situation.
"I wish we could have had more involvement during Esteban's treatment and raised our voice when we witnessed that something (was) not quite right."
When worried Western Sydney mum Angela Garces took 11-week-old Esteban to The Children's Hospital at Westmead just after 1pm on a weekday in October 2015, the doctors immediately suspected sepsis - a known condition for babies born prematurely.
He was lethargic and pale and would not eat.
He had rapidly become unwell - and as a premmie baby was at a high risk for sepsis.
But despite long-established medical advice that mandates antibiotics within an hour, little Esteban waited 170 minutes, or nearly three hours, before receiving the drug - a delay his parents believe could have contributed to his death.
The tiny infant also had to endure being stripped of all his clothes and kept naked in the "cold" environment of the airconditioned emergency department, with his temperature dropping as junior staff repeatedly failed to insert a cannula.
Clinical medical reports and the coronial inquest into his death have highlighted a number of failings in the health system, from confusion with ED staff about what guidelines to follow and a failure to follow official CEC Sepsis Pathway guidelines to delays in getting the antibiotics in his system and the repeated IV attempts.
There was also a lack of senior doctor supervision, inappropriate shift handovers and a lack of bedside electronic records.
The hospital has since brought in significant changes and training.
As his grief-stricken mother told police: "Estaban should have been treated properly and he would still be with us now … we trusted the system."
Mr Franco also told police he was "upset about the repeated attempts to get the needle in" to his baby son.
"I touched Esteban and he felt very cold and I told the staff," he recalled. "They told me they needed to keep him exposed because they are putting lots of needles in for testing. I thought this wrong and told staff … to cover him up.''
WAIT FOR ANSWERS
The grief of the parents has been compounded by the length of time it has taken to get answers about their son's death - a painfully drawn-out 1582 days, or four years, three months and 29 days, for the inquest which, as Mr Franco told The Daily Telegraph, has "shifted from two Coronial Magistrates and more than three Crown solicitors".
"We waited in anguish for over four years in search for a clear answer on what happened to our baby," Mr Franco said.
On the day in question, the baby's aunt Adriana was also in attendance and told police she counted 17 attempts to get a vein for the IV insertion.
"After two hours they finally found a different doctor to come and insert the cannula and he got it in the first time," she said.
"Esteban just looked at me and stopped moving. He was alive but was not moving.
"I thought to myself that he is gone."
While the senior doctors finally got intravenous access to the baby at 2.45pm that afternoon, Esteban was only given saline solution at that point.
Then staff proceeded to do a lumbar puncture and began further discussions over the antibiotic choice.
The delay meant he did not receive the antibiotics in his drip until 4pm.
"The Root Cause Analysis (RCA) team considered that the delay in the administration of antibiotics was potentially a contributing factor to the infant's deterioration and has made recommendations to address this," the final RCA report from the hospital stated.
so much pain
Independent medical expert Dr Mark Lee, who reviewed the case, said a senior doctor should have had input into the management of the baby as soon as he arrived and that after the first two failed attempts to get an IV line, the most senior person on the department should have been called upon to help.
Failing that, "if senior help is unavailable then the use of intramuscular antibiotics should have been given", Dr Lee wrote.
While the deputy state coroner Magistrate Carmel Forbes said it would not be definitively known whether the baby would have survived if given antibiotics earlier, "it was agreed by all parties that it was not appropriate that Esteban was not given the very best chance of survival".
"It was never clear to us why he had to suffer so much pain of IV attempts, hypothermia, lumbar puncture and even surgery," Mr Franco said.
A spokesman for Sydney Children's Hospitals Network said the hospital "extends its sincere condolences to the family of Esteban".
"A significant number of changes and innovations have been introduced at the Children's Hospital at Westmead since Esteban's death, to improve the way care is provided to children presenting with symptoms of sepsis," she said.
These include substantially beefed-up training and an ultrasound to help with patient cannulation, electronic handover tools and more mobile computers providing bedside access. It also includes a Clinical Excellence Commission Paediatric Sepsis Pathway - both electronically and in every area of the ED - to provide a clear process of escalation and direction for a patient who may have sepsis.
Antibiotics must now be given before the delivery of fluids in IV lines and if two attempts at cannulation fail within 10 minutes, then other methods of antibiotic administration will be attempted.
Originally published as Baby's sepsis death a 'warning' to other parents