Abstract
Jacob Antoniades was born normally at 19:13 on 18 April 2003 at Eastbourne District General Hospital. The experts agreed that he suffered no antenatal brain damage. However, he has cerebral palsy as a result of profound hypoxia in the 20 or 30 minutes after birth. The cause of that hypoxia was obstruction of his trachea by a thick plug of mucus. It was alleged that attempts to resuscitate him were inadequate.
It was common ground that by 19:30, Jacob had begun to sustain irreversible brain damage. This case therefore focused upon events in the preceding 17 minutes, i.e. between birth and onset of brain damage.
Jacob was delivered in poor condition, being bluish and floppy. At 19:14 his Apgar score was only 2. A paediatric SHO, Dr Norman, was called and arrived at about 19:17. He was unable to hear air entry to either lung, even after suction of the mouth. Heart rate had deteriorated to <60 beats per minute, and a cardiac collapse occurred at about 19:18.
Next to arrive was Dr Elmusa, the on-call paediatric registrar, at around 19:18. He immediately intubated the infant with a 3.5 mm endo-tracheal tube. This produced no improvement so Dr Elmusa withdrew it and immediately inserted a further tube. A crash call was put out at 19:19. In his witness statement the registrar said that the first tube was ‘full of secretions’ on withdrawal, although he later maintained that this actually occurred with the second tube. The judge decided that the witness statement was correct. He also held that Dr Elmusa did not make this fact known to any of the clinicians who arrived after him, and moreover failed to make any notes of this episode.
Next to attend was Dr Debuse, an anaesthetic registrar with no previous experience of neonatal resuscitation. She noted that Joseph was floppy, making poor respiratory effort and with no evidence of ventilation. She checked the second tube inserted by Dr Elmusa and found it correctly sited. By this time, Dr Norman was compressing Jacob's chest.
Dr Ahmed, the paediatric consultant, then arrived by 19:22. He had been involved in more than 150 neonatal intubations. He left Dr Debuse in charge of the airway, however, and gave her no specific instructions, although he did check that the tube was correctly sited and suctioned the oropharynx.
Adrenaline was then administered and cardiopulmonary resuscitation delivered. Dr Debuse noted that ventilation continued to be unsatisfactory. She removed the second tube and found it completely blocked with secretions. This was the first time that anyone other than Dr Elmusa had noticed a blockage. She therefore inserted a third tube at about 19:25 and suctioned the trachea three times. By 19:27, when the third attempt at suction had failed, Dr Debuse had run out of stratagems because of her lack of training and experience.
The next arrival was Mr Rochester, an operating department assistant and expert in resuscitation techniques, at 19:32 or 19:33. He had been called from home. Unfortunately he was not told at the outset that the problem throughout had been to achieve an open airway. It was not until at least five minutes after his arrival that he came to appreciate that the real problem was with ventilation. He suggested that higher pressures be administered via the endo-tracheal tube.
Finally, Dr Steer, consultant anaesthetist, arrived from home at 19:40. He found a position which was absolutely critical, and considered that Jacob might be lost in a matter of seconds. He tried a fourth tube and decided as a last resort to apply direct suctioning while withdrawing the tube. On withdrawal, a clear oval band of mucus emerged. Dr Steer had never seen anything similar before. Jacob's condition started to improve immediately and his life was saved. However, as previously stated, he now has severe and permanent brain damage.
The experts agreed that a mucus plug was a very rare event in neonatal resuscitation as a cause of obstruction: only one of them had encountered it before. They also agreed that the Newborn Life Support Course (NLS) of the Resuscitation Council represented a statement of standard practice for the resuscitation of neonates. Dr Janet Rennie, a leading neonatologist and editor of the standard textbook on the subject, called on behalf of the Claimant, took the view that at about 19:22 a reasonably competent paediatrician should have recognized that the baby had a low heart rate, was floppy and failing to respond to intubation and ventilation. Every effort should therefore have been concentrated on the airway, the ‘A’ of the ‘A-B-C’ rule of resuscitation.
Dr Rennie considered that the team leader should have taken over the airway himself. In her opinion, what Dr Steer eventually did was not anything that a competent paediatrician could not or should not have known how to do.
Cross-examination focused on a major change in the opinion of Dr Rennie during the progress of the case. Originally, she had thought that failure of resuscitation was due to a tension pneumothorax, not a blockage of the trachea. Leading Counsel for the Trust put it to her that if she, with her wealth of experience, and given time and leisure, had eventually altered her view, how was it reasonable to criticize the clinicians on the ground who were dealing with an emergency? She responded that it was not until she had seen the Trust's witness statements and a note by Dr Steer in his personal diary, rather than in the case records, that she realized clearly what had happened.
Professor Weindling, expert neonatologist for the Trust and the only expert to have personally seen a mucus plug in a newborn child, considered that staff below the grade of consultant anaesthetist should not be criticized for failing to recognize the problem. He described Dr Steer's manoeuvre as ‘a stroke of genius’.
Held: the defence experts were increasingly uncomfortable when tested under cross-examination. It was not unreasonable to expect competent paediatricians to apply the manoeuvre used by Dr Steer. To have carried on with CPR and drugs was at best a distraction and at worst useless. Dr Ahmed had known from his arrival that the airway was not permitting ventilation, and allowed himself to lose focus. The fact that Dr Ahmed did not reveal his knowledge of the situation to others was negligent. By 19:22, or 19:25 at the latest, once other causes were eliminated, obstruction was the only conclusion open to the paediatricians. By then, this should have been obvious.
Dr Elmusa was in breach of duty for contributing to the lack of understanding in other team members as to the nature and extent of the airway problem and in depriving them of the chance to apply a technique before irreversible brain damage was suffered.
Had direct suction been applied by 19:27 or 19:28, as it ought to have been, the probability was that the blockage would have been cleared by 19:30, thus avoiding Jacob's brain damage.
There would therefore be judgment for the Claimant.
Simeon Maskrey QC (instructed by Parlett Kent) appeared for the Claimant. Michael de Navarro QC and Roger Harris (instructed by Capsticks) appeared for the Trust.
Comment
The judge expressly stated that he reached his conclusions with reluctance, given that the events in question took place over a matter of minutes. This was, of course, an emergency, but clinicians are trained to deal with these. Critically, there was a failure to pass on vital information and to follow the basics of resuscitation procedure. These facts, combined, led directly to the patient's brain damage. This does not seem to have been an example of panic during an emergency, but rather a failure to follow basic good practice. Two other articles in this issue also provide perspectives on this interesting and unusual case.