A four day old Nelson baby who suffered a cardiac arrest within 12 hours of discharge from Burnley General Hospital, died of natural causes, an inquest has concluded.
East Lancashire Coroner Mr Richard Taylor said there was no other conclusion he could reach after hearing evidence on day two of the inquest at Burnley Town Hall from the pathologist who carried out the post-mortem on Fletcher Kennedy.
Fletcher’s 35-year-old mother Gemma Smith, of Sherwood Close, Nelson, who was joined by 27-year-old father Sean Kennedy and other family members, had told the inquest on the first day her son had been “inconsolable” and “unsettled” after initially feeding well from birth on February 14th, 2013.
But Miss Smith had said Fletcher appeared “so grey” two days after birth, she had put pictures onto a social networking site of her son taken when he was alive, but said friends had commented in shock thinking they had been taken after his death.
The hearing was told by Miss Smith that she had raised concerns with midwives about Fletcher not feeding, sleeping or urinating and going pale, describing his nappies as “bone dry”.
Miss Smith also questioned whether it was appropriate to have sent a baby home who had been unsettled for two days.
The two midwives on duty on February 15th and 16th, 2013, Lola Wild and Heidi Needham, told the inquest that they recalled Fletcher being unsettled but both said they had observed feeding and put his unsettled nature down to wind and natural feeding not yet being established between parent and child.
Concluding, Mr Taylor said: “The loss of a child is always a terrible thing whatever age but in his fourth day of life, our hearts go out to you, to a mother and father who had dreams, hopes and expectations for their newborn son.
“It’s only natural that parents ask not only why has it happened to us but why has it happened at all.”
Mr Taylor said that he didn’t think it unreasonable to discharge both mother and baby from hospital after checks and said Gemma herself had admitted she wanted out.
He also said he didn’t criticise memories of midwives, who relied on medical notes, and that it would be an “unusual mother” who didn’t memorise every detail.
Mr Taylor added: “I have no doubt she (Miss Smith) expressed concerns and I have no doubt that they were listened to.”
He went on: “I do hope to some extent the family’s concerns have been allayed. All we can say is that it was an unknown natural cause.”
Earlier in the day, Dr Nadia Burgess from the Royal Manchester Children’s Hospital, who carried out the post-mortem, told the inquest that the cause of death had been “unascertainable”.
She told the inquest everything appeared normal with Fletcher and there was no evidence of any infection.
On day one, the inquest heard that Fletcher had been born at a healthy colour and at 7lb. 7oz. on February 14th last year but had a pad of skin on the back of his neck and a heart murmur.
After a referral to neo-natal specialist Dr Thangavel Chandrasekera, the skin was viewed as nothing concerning and the heart murmur of “no significance”.
Miss Smith told the hearing that, the following day, everything seemed fine, but by the evening Fletcher was “grizzly” and “very unsettled and wasn’t feeding at all”.
Fletcher was seen by paediatrician Dr Chi-Ning Mo on February 16th where the heart murmur was looked at.
The inquest was told babies can develop a heart murmur in the first few days of life as they make the natural adjustment from foetal to neo-natal life.
On the perceived pale and greyness of Fletcher on February 16th, Dr Mo told the hearing Fletcher’s oxygen saturation and blood pressure were “completely normal”.
She added: “There was nothing to alarm me to think there was a problem with circulation to the skin.”
Fletcher was discharged from Burnley General Hospital on the afternoon of February 16th.
Miss Smith said she heard the moment Fletcher stopped breathing, having decided to sleep downstairs with partner Sean Kennedy and her son, such was their concern for the baby.
An ambulance was called and Fletcher was rushed to Blackburn Royal Hospital in the early hours of February 17th after suffering a cardiac arrest.
Dr Betty Wamola, from the Blackburn hospital, told the inquest that repeated efforts by medical staff to resuscitate Fletcher were unsuccessful.