By Niall McCracken
THE father of the third baby to die of pseudomonas at the Royal Victoria Maternity Hospital in January has spoken for the first time to say the Health Minister, Belfast Trust and the team set up to review the deaths have all failed in their promises to provide his family with answers about what happened to their baby.
He has raised questions about why the hospital was not using sterilised water on the ward as had been the practice before, and he has described the family being kept in the dark from the moment ‘Baby 3’ was born right up to the present day. He claims that:
:: their baby was brought onto the ward, healthy, after two babies had died of the infection, but they were not informed;
:: their child suffered cuts during treatment in the days before infection set in, but the trust says there are no notes of this and has still not engaged with them on this subject;
:: when their child became sick they were told it was “a bad bug” and still not told of the pseudomonas outbreak;
:: on the eve of their baby’s death, they were handed a leaflet about pseudomonas, but given no context as to why;
:: the Troop review into the deaths was “patronising” and gave the families little chance to provide their perspective on events; and
:: since Baby 3’s death, a lack of contact from the Department of Health and Belfast Trust about specific concerns the family has left them doubting that the same mistakes will not happen again.
While the father of Baby 3 has asked to remain anonymous to protect the identity of his family, he says his decision to speak out has been influenced by a lack of contact from the relevant authorities.
In an exclusive interview with The Detail, he says the past number of months have been a “complete nightmare” and that his family will only be able to accept what happened to their child when all their concerns have been acknowledged and addressed by the authorities.
In a previous article we revealed that the family of Baby 3 had serious concerns about gaps in hospital records that failed to make note of cuts present on their baby’s skin, just days before their baby died.
Any cuts, abrasions or damaged skin can increase the risk of infection.
At the end of January the Health Minister Edwin Poots asked RQIA to undertake a review of the circumstances contributing to the occurrences of pseudomonas infection and colonisation within neonatal units in Northern Ireland. The final report was published at the end of May, but contained no reference to the family’s concerns, even thought they had specifically raised it with the review team, the Belfast trust and the Minister ahead of publication.
The father of Baby 3 says they have not been contacted directly by anybody since the publication of the report.
He continued: “We’re feeling really let down at the minute. We’ve had no contact from anyone since the report came out and we need final answers. When we met with the Minister a couple of months ago and told him about these concerns, we felt he was genuine, he told us he was going to get all the answers we needed and we haven’t had those answers yet.
“We want to know why this happened to our baby. It’s just been a complete nightmare trying to get on with life and put it behind us, but we just feel we can’t at the minute. We just need these questions answered and that’s why I’ve made the decision to speak.”CUTS TO THE SKIN
Baby 3 was born prematurely on January 11 2012. On January 14 2012, the family received a phone call from a nurse advising that their baby’s skin had been torn. The significance of these cuts was unknown to the family of Baby 3 at the time as they were unaware that pseudomonas has claimed the lives of two babies just days before.
The family would subsequently learn that this incident seemed to be “missing” from the bundle of detailed medical records outlining their baby’s care.
Despite written correspondence sent to the trust’s Medical Director, Dr Tony Stevens, about the matter, the family’s legal team have not received any response to this concern.
In a statement the Belfast trust said:
“We appreciate this is a very difficult time for all concerned, however we are not permitted to discuss the care and treatment of individual patients.
“However we wish to advise that we have engaged with the family you have mentioned throughout this extremely difficult time. We are currently following up on the issues they raised in their recent correspondence and we will continue to try and resolve the remaining issues.”
The father of “Baby 3” says his family are convinced that this incident forms an important part of understanding what happened to their baby.
“When you see the bundle of notes that contain a massive amount of detail about our baby’s care over eight days, then to suddenly have next to nothing for the 14th –it doesn’t make any sense. We feel that the cuts could have been instrumental in our baby getting the infection in the first place, but there’s nothing in the notes to even acknowledge them.”
He is also highly critical of the report and how the review team chose to handle the family’s input into it.
“We weren’t even given enough time to respond to the report; it was posted out to us on a Friday and was published that Monday. Even if our concerns had been acknowledged in a separate letter that wasn’t published in the report, that would have been something, but to ignore it completely we just feel is very patronising.”
In a statement RQIA said:
“Those families who met with the team provided a clear picture of their circumstances and the issues they faced as a result of the pseudomonas outbreaks. During these meetings the review team advised families to follow up any specific clinical concerns with the relevant trust. RQIA also examined the communications arrangements within organisations under review, and made a recommendation to improve how families are kept informed of issues affecting them."FIRST BORN
The Troop review found that in the five neonatal units in Northern Ireland it was normal practice to use tap water for nappy changes. However, the father of Baby 3 claims that when their first child was born prematurely in May 2009 and treated in the same neonatal ward at the Royal Jubilee Maternity Hospital, sterile water had been used for everything.
He said: “When our first baby was born on the ward, it was insisted by staff that sterile water was used for nappy changes and for his eyes.
“We can’t understand why the ward was using tap water this time round, especially in our case when the trust knew there was pseudomonas on that ward for three or four days.”
The policy in relation to infant hygiene in the Royal Jubilee’s maternity ward was developed in 2002. It outlines a number of measures that should be put in place when assessing and attending to infant hygiene needs. This included the use of sterile water at all times and it makes reference to using a “bowl of warm water” within the ward.
However following the outbreak, the policy was updated in March 2012 and while sterile water is still listed as a requirement, the use of a “bowl of warm” water is no longer listed.THE LEAFLET
The family believe the Troop report did very little to address their experience in the lead-up to their baby’s death on January 19. The father of Baby 3 says they only became aware of the term pseudomonas when they were handed a leaflet by a nurse the day before their baby’s death.
“Our baby died on the Thursday (January 19), I realised things were serious on the Tuesday because our baby had a bad bug and some internal bleeding. There was blood vomiting out of the mouth and nose and we were told to get the baby christened. I knew then it was extremely serious.
“We were handed this leaflet on the Wednesday, but it didn’t say anything about how serious the infection was and there was nothing in it to prepare us for what might happen.”
The family’s solicitor has written to the PSNI asking them to investigate the circumstances surrounding the death of their baby under corporate manslaughter legislation. They are currently awaiting a response.