Hospital bosses have apologised after a coroner found that an 11-week-old baby died after delays in identifying and treating her life-threatening condition.
Nova Maynard Parsons was suffering from a bowel obstruction – and, although a coroner said that Nova died from natural causes, she added that delays and neglect had played a part.
Nova’s father, Andy Parsons, 36, an IT support technician, said: “We would have liked the doctors to have listened to and acted on our concerns. We didn’t always feel like they took our concerns seriously.”
Nova’s mother, India Parsons, 29, a craft event co-ordinator, said: “It felt as though we were treated as over-cautious parents. Parents do know what’s normal and when their children are not themselves.”
It emerged at an inquest that, after surgery in Brighton and a discussion with the surgeon afterwards, the family were unclear about her condition. Only when Mr Parsons asked more directly did it come to light that Nova was close to death.
Nova’s grandmother, Stef Maynard, said: “It’s got to be said plainly so that parents understand it. You can’t sugar-coat it.”
The inquest into Nova’s death took place over four days at the Coroner’s Court, in Horsham, ending on Thursday (17 April).
The senior coroner for West Sussex and Brighton and Hove, Penelope Schofield, said: “On Wednesday 11 March 2020, Nova died at the Southampton General Hospital, having been transferred to the paediatric intensive care unit from the Royal Alexandra Children’s Hospital, in Brighton.
“Nova died from small intestinal necrosis, caused by a bowel obstruction which was not identified promptly by the treating clinicians following her admission to the Royal Alexandra Children’s Hospital on Saturday 7 March 2020.
“By Monday 9 March, surgery was indicated but there was a lack of appreciation of the deterioration of her condition.
“By the early hours of Tuesday 10 March 2020, Nova’s clinical condition was now acute and there was an urgent need for life-saving surgery.
“The delay in undertaking a timely surgical review and arranging emergency surgery was a causative factor in her death and therefore Nova died from natural causes which were contributed to by neglect.”
The coroner said that there had been a failure to conduct a surgical review and a failure to arrange surgery and “a gross failure to provide basic medical attention to someone in a dependent position”.
Nova was born two weeks overdue on Sunday 22 December 2019 at the Princess Royal Hospital, in Haywards Heath. She was suffering from a rare but treatable problem with her bowel and intestines and underwent surgery at the Royal Alex 36 hours later – on Christmas Eve – and spent her first month in hospital.
Mrs Parsons told the inquest: “The general consensus was that Nova would be put back together and lead a normal life … Nova was then placed in the Trevor Mann Baby Unit for four weeks.”
She said that Nova “was full of personality” and “so alert”. She enjoyed looking around and loved being propped up with a pillow to look out of the window over Brighton.
After her operation, she made slow but steady progress, the coroner said, and Mrs Parsons said that she was a happy, expressive and smiley baby.
On Friday 6 March, Nova sneezed and fell off a sofa on to a thick rug at the family home in East Grinstead. Mrs Parsons told the inquest: “We checked her over but there were no signs of any marks, bruises or injuries.
“That same day we went over to meet my sister in Hailsham as planned. Nova was not acting herself and seemed grumpy and unsettled.”
Later, Nova was sick several times and her parents said that “she was not herself”. After calling 111, they took her to the Royal Alex.
The couple arrived at 10.50pm. Mrs Parsons said: “They found no obvious signs of head injury. They wanted to keep checking on her and so she was admitted for the night in the A&E ward.
“Only one parent was allowed to stay overnight at the hospital and so I stayed with Nova while Andy slept in the car and I stayed by her side.
“(The next day) we were told that due to Nova’s vomiting they suspected gastroenteritis and we accepted this diagnosis.”
Mrs Parsons spoke to doctors and nurses at the Royal Alex about her growing concerns as the signs of Nova’s worsening condition became clearer but felt that her concerns were being dismissed.
A serious incident review “into the delayed recognition of a deteriorating baby” later highlighted cognitive bias and human error as well as medics caring for a high number of emergency patients.
Mrs Parsons told the inquest: “It really felt like no one was taking responsibility for Nova and she was being passed around.”
Nova was in such pain and distress that Jigna Sheth, a paediatric surgical consultant, prescribed morphine although another surgeon later appeared to disagree.
The parents recognised the signs that had led consultant paediatric and neonatal surgeon Saravanakumar Paramalingam to carry out life-saving surgery on Christmas Eve.
But the doctors decided to continue observations and “conservative management” beyond 48 hours – the point that Mr Paramalingam told the inquest he regarded as too long for a baby lacking “anatomical robustness”.
A middle-grade specialty doctor, Mohammad Asif, carried out a review at 4.20am on Tuesday 10 March, more than two hours later than expected, the inquest was told. He disputes the timing and the General Medical Council (GMC) is looking into a number of matters including this discrepancy.
Mr Asif believed that Nova needed urgent surgery but did not tell the on-call consultant. Instead, he decided to contact Mr Paramalingam a few hours later.
Mr Paramalingam arrived at the hospital at 7.30am and cancelled the other operations that he was due to perform.
By 10am, Nova had been sent for surgery during which the scale of her problems became clear – as well as a need for intensive care after the operation.
She continued to lose blood and it proved increasingly hard to keep Nova stable – and there were no suitable beds in Brighton.
The Royal Alex did not have a paediatric intensive care unit and there was no suitable bed at the Royal Sussex County Hospital either.
She was sent by ambulance, accompanied by her parents, to the paediatric intensive care unit in Southampton where consultant paediatric surgeon Nigel Hall examined her.
At about 9pm, he spoke to Nova’s parents. Mrs Parsons said: “He was very frank and said that Nova’s survival rate was very slim.”
Nova had a second investigative operation that day in Southampton but Mr Hall found only about 6in or 15cm of functional bowel remaining which was not compatible with life.
Mr Hall felt that Nova was trying to die and, considering the intensive life support that Nova was receiving, the parents decided that the time had come to withdraw that life support at about 4am.
Mrs Parsons told the inquest: “She died in my arms within a few minutes.”
The first coronavirus lockdown followed shortly afterwards as the serious incident investigation got under way, with consultant neonatologist Ryan Watkins making contact with Nova’s parents.
Mrs Parsons told the inquest: “He explained to us in an email that the main conclusion of the report is that the severity of Nova’s condition was not properly recognised which led to an avoidable delay in her surgery, with an apology.
“To read that, officially, was heartbreaking. Knowing that our concerns in the hospital were real and that no appropriate action was taken for Nova as she was laying there dying.”
According to the serious incident review: “Nova received several medical and surgical reviews over a four-day period.
“In retrospect it can be seen that there was a failure to appreciate that Nova’s condition was worsening which led to missed opportunities in offering surgical intervention.
“The investigation was unable to clearly identify the specific reasons for the lack of recognition of Nova’s deterioration and found that the clinical reviews were senior and thorough, with concerns appropriately escalated. Following each review the plan for conservative treatment continued.”
Observations were not carried out as often as they should have been, not helped by a lack of clarity over frequency, and the shortcomings were compounded by gaps and inconsistency in record-keeping.
The investigation report also said: “Had Nova been observed more frequently, there may have been an opportunity to see a visual ‘trend’ on the observation chart which is likely to have prompted recognition of Nova’s deterioration at an earlier stage.”
The report ended with a three-page actin plan containing 13 recommendations for staff at University Hospitals Sussex NHS Foundation Trust, which runs the Royal Alex.
Mrs Parsons told the inquest: “You could see she was incredibly poorly. We did the right thing. We took her to hospital. We couldn’t do any more. We put her life in other people’s hands.”
After the inquest, the deputy chief executive of University Hospitals Sussex, Andy Heeps, said: “We accept and deeply regret that Nova did not receive the care she should have in 2020 and would again like to express our deepest condolences and sincere apologies to her parents for their loss.”
Dr Heeps added: “Following discussions with Nova’s parents and in response to the recommendations of our investigation, we have made changes to how we provide our paediatric surgery service to improve continuity of care and consultant supervision.
“We have also provided further training for clinicians, and lessons from this tragic case have been shared across our hospitals.”
Mrs Parsons told the inquest: “The outcomes to this report were lots of recommendations and changes of procedures to make sure nothing like this happens again – to learn from their mistakes.
“Since that day, when we have been in contact with a member from the NHS trust, they always mention how invaluable the lessons are that they have learnt.
“However, as much as we don’t want another family to go through what we have, we did not have Nova for the NHS to learn from.”
She added: “Even now, there is a daily struggle we both face of being without her. It’s not only us who are suffering. Our families are too.
“We wanted to have a big memorial day for her with friends and family but due to covid we were unable to this.
“Losing our daughter at 11 weeks old was horrendous, especially in the way we did.
“For us to hear that her life could have possibly been saved with alternative care is something that we will never be able to get over, particularly when we expressed our concerns when it was most vital.”
I can’t even begin to imagine how absolutely heartbreaking this must have been for the parents and even for the staff that are now wishing they could have done more to prevent this tragedy. Having been to A and E at the Royal Sussex I am sure this is one of many mistakes. It felt like something out of one of those hospitals getting Red Nose Day money in a third world African country with people lined up in the corridors and beds packed in so closely together that patients could reach over and touch the patient in the next bed. The staff looked exhausted and the building looked like it was going to collapse.
So scary. Poor Nova didn’t have to suffer and her parents did their utmost. I wonder if Martha’s Law could’ve helped to get a 2nd opinion if it had existed then. Or I guess there were second opinions and didn’t help. My heart goes out to the whole family.