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Poor post-injury care
The doctor at the centre of the report into the death of baby Simeon Cottle listed the baby’s death as “a surgical event/surgical error resulting in death of the patient.” This admission, according to the 60-page report, is akin to an “admission of a prima facie case of negligence.”
The report, which was only completed and handed over to the Attorney General on June 6, was obtained by the Sunday Guardian and paints a grim minute by minute, detailed picture of the events leading up to the time baby Simeon was delivered via C-section and the efforts to save his life hours later. According to the report, the on-call obstetric consultant “failed in her responsibility.”
The report also recommended that a third doctor named in the report, who had failed to participate in the investigations, was possibly guilty of professional misconduct and should be sent before the Medical Board of T&T. The report noted “no case identical to the injury sustained by the infant Cottle has been reported” in medical history. “In this case, it is clear that the injury occurred from the failure to exercise the degree of skill which was required in order to perform this procedure,” the investigative committee noted.
The detailed report traced the incident from the time the mother Quelly Ann Cottle was admitted to the events during her caesarean section, followed by the attempts to save the almost four-hour-old baby. Investigators highlighted several missteps in the course of treatment including the doctor’s speed while performing the operation. The report also found that while the foetus may have been “compromised,” there was no immediate need for the child to be delivered.
“Reviewing the results of investigations described above, there was not a need for ‘urgent’ delivery but certainly a need for close surveillance,” the report found. The entire procedure, the report noted, lasted 24 minutes, with just a three-minute interval between the start of the operation and delivery of the foetus. According to the investigations, several of the medical staff interviewed referred to the doctor as a “fast operator.”
“This was an elective procedure with no urgency for delivery of a very small pre-term baby and a more measured approach might have reduced the risk of complications,” the report stated. It also questioned whether there was any consideration given as to whether the registrar was capable of delivering a premature infant weighing less than 1,000 grammes.
The report also noted that the registrar “incised the lower segment of the uterus with a knife, expecting the uterine wall to be relatively thick” but the incision went straight through and “opened the uterus.” “Without realising that he had entered the uterus (there would probably have been very little amniotic fluid) he made a second pass with the knife, which incised the fetal head,” the report stated.
The report noted that the doctor then inserted a six-inch artery forceps into the centre of the wound, “expecting to penetrate the amniotic sac and opened the tips, causing further injury to the skull and brain.” The baby lived on for three hours and 48 minutes after the incident and succumbed to injuries despite efforts to save him.
At first, the cut to baby Simeon’s skull was estimated at four cm long but a pathologist report stated that the cut was actually seven cm long from the left to the right side of the head and that the baby’s brain was exposed. There was also a “puncture wound to the skull.” In the hours between delivery and death, the baby’s injury was sutured at first but those sutures removed and the wound was packed with a gel foam and then resutured.
Errors in the autopsy
The baby’s post-injury care was also examined and found wanting as there was no replacement of the blood that was lost through the laceration. “Inadequate measures were taken to manage the infant and to replace blood lost,” the report stated. The investigators found that more was done to stem the bleeding than to replace what was already lost. They also found that six gauze pads were soaked through, yet there was no evidence that staff attempted to replace the lost blood.
“The major effort in the delivery room was directed towards arresting the blood flow. Little or no effort was made towards managing the needs of the 870 g infant and certainly the effect of acute blood loss,” the report found. The baby arrived at the Neonatal Intensive Care Unit (NICU) some two hours and three minutes after birth, and resuscitative measures were started some 35 minutes after that. The baby was also given six doses of adrenaline; the report stated that was three times the accepted limit.
There were limited notes on the incident, with investigators seeing evidence that some notes were placed on the patient’s file up to four days after the incident occurred. The first medical autopsy performed five days after the baby’s death also contained several errors.
“The findings are non-specific, that is, not finite enough. The location of the laceration is not identifiable from their description. It does not define its depth...One cannot, therefore, determine from the autopsy report where the source of the bleeding was. It confuses an ‘incised wound’ with a ‘laceration.’ The report further picked apart the first autopsy, saying that it was written up by a junior pathology officer and signed by the consultant pathologist.
The junior pathologist found that the laceration to the right of the baby’s brain was responsible for the baby’s death. “This is not correct; the primary cause of death in our opinion was hypovolaemic shock due to uncontrolled blood loss,” the report noted.
Burden of responsibility placed on the least experienced doctor
The committee found that the burden of responsibility was placed on the least experienced, least competent members of staff. It also found that the on-call obstetric consultant—named in the report—was informed of the events but never came to the hospital. In the report, that consultant told investigators that though she had been informed of the injury, the infant was being cared for “so she did not feel there was any more she could contribute at the time.”
The investigators found that even when informed of the infant’s death, the consultant did not come to the hospital. “The consultant’s first duty of care is to their patient. We would have expected the consultant (name called) to see Ms Cottle personally following delivery. The consultant’s second duty of care is to their staff. We would have expected the consultant to attend in order to provide support for her registrar and the rest of the team involved in such a traumatic event,” the report stated.
The committee was chaired by retired justice of appeal Mustapha Ibrahim and included United Kingdom specialist Dr Melanie Davies and retired neonatologist Petronella Manning-Alleyne.