SINGAPORE— An 11-day-old baby delivered in KK Women’s and Children’s Hospital (KKH) died in 2021 due to a type of injury related to a decrease in oxygen or blood flow to the brain.
Although there was no foul play in the newborn’s death, the investigation found that the hospital’s lack of continuous documentation of the baby’s vital signs “was not ideal”, according to State Coroner Adam Nakhoda.
He noted that the baby’s vital signs were not recorded from the seventh minute after birth until he was taken back to the operating theatre.
“I found that the lack of continuous documentation of (the baby’s) vital signs was not ideal, ” Adam Nakhoda said.
He made these remarks in a report regarding the findings into the death of the baby, which was made available recently, according to CNA.
KKH encouraged to consider continuous documentation of a newborn’s vital signs
Adam Nakhoda encouraged KKH to review its procedures to consider continuous documentation of a newborn’s vital signs.
The report said the baby’s mother was delivering her first child when she was admitted to KKH in April 2021.
She underwent an emergency caesarean section after vaginal delivery by vacuum, and forceps were unsuccessful.
The medical team also detected a slow foetal heart rate for eight minutes during delivery.
The baby was born at about 4.30 am, with three tight loops of the umbilical cord around his neck.
When the cord was removed, the baby was noted to have a “fair cry”.
As the baby’s heart rate and oxygen saturation were less than optimal, KKH’s neonatal resuscitation team gave the baby continuous positive airway pressure (CPAP) via nasal prongs until his condition improved.
The report mentioned that the baby was “observed to be vigorous and have a “good cry” at six minutes after delivery; hence the CPAP was discontinued, and examination findings were normal at the time.
At 5 am, the doctors were called away to attend to other medical emergencies, while the baby remained in the operating theatre in the care of a senior staff nurse, named only as SSN KJ in the report.
SSN KJ said the baby’s oxygen saturation and heart rate were normal when measured via a probe attached to his palm.
But the nurse noted that the baby’s cry was “quite weak”. She contacted the special care nursery ward for his transfer, and then took the baby out of the resuscitator, and placed him on a transport cot to transfer to the viewing room for his father to look at him.
Adam Nakhoda noted that the father who was recording a video observed that his child was quiet, sleepy and responding slowly.
The father asked the nurse “if the baby was still sleeping”. While not replying to the question, SSN KJ checked the baby, who appeared limp.
The baby was not breathing spontaneously and not showing any spontaneous limb movements. Hence the nurse took the baby to the operating theatre again, put him back on the resuscitator and reattached to the probe.
At 5.22 am, the nurse activated a neonatal code blue emergency and the medical team, including an on-call consultant, an on-call senior resident and two on-call junior residents, went to attend to the baby.
At 5.25 am, the baby was showing no response to stimulation. He was immediately transferred to the neonatal intensive care unit(NICU) and connected to a ventilator.
The baby’s fraction of inspired oxygen (FiO2, an estimation of the oxygen content a person inhale) had decreased to 21 per cent at the point.
A magnetic resonance imaging (MRI) indicated that there was swelling and bleeding in the baby’s brain.
Father questioned why his child was not put on a ventilator
By the fifth day after the baby was born, his condition worsened. The parents agreed after consideration on day six to withdraw care after discussion with the medical staff.
The 11-day-old baby was pronounced dead on 12 April 2021.
The baby’s father raised the question during the coroner’s inquiry, why his child was not put on a ventilator to assist his breathing after he was noted to have breathing difficulties.
A medical report prepared by a consultant at KKH, said the baby was born limp with a slow heart rate, and the medical team “had to go through the standard resuscitation process”.
Reading not captured by KKH’s electronic medical records system
CPAP was discontinued six minutes after the baby’s birth as he was deemed to be breathing sufficiently well.
According to KKH’s protocol, he was to be transferred to the special care nursery as he had been subject to resuscitation.
At the time, the baby was connected to a probe to measure his oxygen saturation and heart rate. But there was no electronic record as these readings were not captured by KKH’s electronic medical records system.
The probe was also disconnected when the baby was placed in the transport cot and brought to the viewing room.
KKH said will ensure newborn’s vital signs documentation “is kept until the newborn is handed over”
KKH representative said they working to ensure documentation of a newborn’s vital signs “is kept until the newborn is handed over” to medical teams at the respective clinical areas.
They also emphasised that neonatology teams should “ensure that any newborn babies who require oxygen supplementation should be accompanied by medical personnel”.